I
When Dr. Mitchell invited me to speak here tonight I had some misgivings, realizing that, in some quarters, efforts have been made to put on the “spot” Foundations in general and our Fund in particular and that I would be facing a group of doctors, some of whom at least would be harboring the impression that the President of the Milbank Fund must be an officious sort of hybrid in whom ignorance and prejudice are unhappily blended. But the sincerity and cordiality of your introduction, Mr. Chairman, relieves my mind and touches me deeply.
Normally, my preference is to work and not to speak. On the relatively infrequent occasions when I have been persuaded to emerge from my customary obscurity I always feel that I am violating one of the sound precepts given me by my wise father, who used to say that it is better for a man to take a back seat and be discovered than to take a front seat and be found out.
However, when misunderstandings arise and assume regrettable proportions between groups whose interests and purposes call for mutual understanding and cooperation, one's personal preferences should yield to the exigencies of the situation even at the price of compelling you to listen with such patience as you may possess to a layman.
Not long ago, in New York, when the Bellevue-Yorkville Health Center was turned over to the Department of Health I made a passing reference to the subject of which I would speak more fully this evening. In an endeavor to summarize the nature of the complaints against our Fund, which had been voiced privately and publicly, I said that the Fund has been charged with advocating State Medicine; of seeking to demote the members of the medical profession to the level of government clerks; of placing the emphasis on the quantity of medical care rather than on the quality of medical care; of destroying that priceless human as well as traditional professional relationship between doctor and patient which has been one of the glories of the medical profession from time out of mind; of regimenting and sovietizing a group whose training costs more in time and money than the training of almost any other group in the country; and of blaming the doctors because many people do not receive adequate medical care. And all this, it is claimed, is being attempted by a lay organization which is asserted to have little knowledge of medical problems and scant interest in acquiring that knowledge from the only source from which it can be obtained—namely, from the medical profession.
I then added that if all, or any appreciable part, of these charges had any foundation in fact, speaking for myself and for the Directors and staff of the Fund, I would be the first to concede that the medical profession has a just grievance, and I concluded with a denial that the charges have, in fact, any substantial foundation.
This evening I would like to develop affirmatively the position of the Fund in the field of health and the relations it would like to see established between it and all the other groups operating in that field in which, of course, the members of the medical profession are obviously preeminent.
It would be well at the outset to say that our Fund, through its Board of Directors, decided in 1921, for reasons which I will mention later, to make the public aspect of health its major field of interest. At that time Edward W. Sheldon was President of the Fund and Elihu Root was one of the interested and active Directors. In furtherance of that general policy it set up two auxiliary committees to examine into this general subject, to make recommendations as to procedures calculated to promote the health of the public, and to review from time to time the adequacy and effectiveness of such procedures. The first of these auxiliary committees was a small group called the Technical Board, of which the first chairman was the late Dr. Hermann M. Biggs, and which has met frequently and regularly since its organization. The second of these auxiliary committees was a larger group, called the Advisory Council, of which the late Dr. William H. Welch was the first chairman—a position he filled with great distinction until shortly before his death. The Advisory Council is kept in touch with the activities of the Fund by bulletins released from time to time and meets once a year in a two-day session during which it subjects the program of the Fund to critical analysis and makes suggestions as to future programs.
Both of these committees are made up of representatives from all of the groups actively engaged in the broad field of health—public health, the private practice of medicine, hospitals (public and private), nursing, social and welfare organizations. Whenever a question arises which involves a matter of policy or the expenditure of money the Board of Directors is free to seek the counsel and advice of the Technical Board but the final decision remains with the Directors of the Fund.
For example, the Directors authorized the series of health demonstrations with which you are doubtless familiar and which were designed to ascertain what results could be expected from a coordinated health program in which physicians, public health officers, and voluntary health agencies participated; what such a program would cost; and to what extent the community would, after a time, assume such costs. These health demonstrations were authorized by the Directors and, judged by the overwhelming evidence in the files of the Fund received from many sources, the Directors have no question as to their medical and social value.
As to methods of meeting the costs of medical care, however, a different situation exists. Here the Directors have taken no action, nor, for that matter, has any recommendation on this subject been made to the Directors by the Technical Board. In this matter, the staff of the Fund, with the knowledge and informal approval of the Directors, has conducted a series of studies as to methods in operation in this country and in procedures in operation in many other countries set up to deal with this problem. No final report of these studies has been made. In fact, the studies themselves have not been completed. Interim reports embodying tentative proposals have been released by the staff for the purpose of encouraging discussion and criticism. Therefore the Directors of the Fund are free to take any one of three courses in relation to this subject: (1) They may concur in whole or in part with such conclusions; (2) they may favor some other solution of the problem; or (3) they may abstain from taking any position whatever and simply make the studies of the staff available to those interested in the subject.
II
In order to get a proper perspective of the position the Fund seeks to occupy in the field of health it will not be amiss to take a look at its origin. Spiritually and financially it is the embodiment of a wise, generous, and charming woman who, fifty years ago, began a series of noteworthy gifts which continued uninterruptedly until her death in 1921 and whose carefully considered philanthropic philosophy the Fund, which she established in 1905, adopted as the basis of its own policies.
Elizabeth Milbank Anderson was one of those rare souls who combined a brilliant mind, a love of humanity, a generous nature, and a keen sense of humor. She was an unquestioned individualist but with a profound sense of her social obligations. She mistrusted fads and visionary theories as solutions for current problems but the honesty of her mind made it impossible for her to ignore a problem even when its solution called for changes in an established procedure. She was a conservative by inheritance and environment but one who understood that the world does not stand still and that when conditions change the cause of conservatism is best served, not by an unreasoning resistance to any change whatsoever, but rather by a willingness to make reasonable changes, in form and procedure, while preserving the sound principles which, like the eternal verities, persist because they are, in fact, based on truth.
With such a tradition and such an inspiration it would be quite out of character if our Fund should seek to undermine those foundations of the practice of medicine which have been built up, tested and found good over the years, or to discredit the frontline troops upon which every one must rely to win the common fight for better health for the people of the United States.
As often happens in human affairs a shattering personal loss had a profound effect upon Mrs. Anderson's attitude toward philanthropy. Her only son died of diphtheria when he was still a little boy. As her brave spirit rose to meet the most crushing blow that Fate could have dealt her, she began to give reasoned direction to her generous impulses which up to that time had been the result of emotional rather than of rational processes.
From that time on, imperceptibly at first and more obviously as the years went by, she looked upon avoidable sickness and premature death as twin tragedies ever menacing human happiness. Health for all of the people became her paramount interest and preventive medicine began to assume in her mind equal importance with curative medicine.
Poverty always stirred her sympathies, but here again a careful analysis of the causes of poverty placed sickness at the head of the list. So from whatever angle she approached the problem of how to make the best use of her money she found but one answer—an attack upon sickness as Public Enemy Number One.
This conviction was the genesis of the Fund and this is the trust which the Directors of the Fund assumed and have endeavored to fulfill. A little later it will be well for us to take a “look at the record,” as Al Smith says, and see to what extent and in what manner the Directors of the Fund have kept faith with its founder. But, before doing so, it will not be amiss to take a broad and sweeping view of the general conditions and trends going on all about us and of which the question of medical economics is only one phase.
The world is in a turmoil of conflicting philosophies.
The Great War was a titanic physical struggle between armed forces involving also, of course, a conflict of ideas and ideals which, however, was easily stated and easily understood. Today there is being waged an equally titanic struggle between two conflicting schools of thought—Socialism and Individualism. In their wide ramifications and implications they affect the daily lives, habits, and welfare of the average person more directly and more consciously than that devastating physical encounter which ceased on Armistice Day in November, 1918.
This peacetime war is one of the products of the Great War but it is not a consequence of it. Our present battle of conflicting ideas and interests was bound to come sooner or later. The Great War merely hastened it.
That war conscripted the youth of the country who were physically and mentally fit. This ideological war conscripts each and every one of us—old and young, rich and poor, strong and weak. No individual and no group can claim exemption.
And so I submit that the problem of medical economics and its solution represents only one phase of a larger and more general economic, social, and political controversy. That phase, dealing as it does with the subject of the health of the nation, is naturally of special interest and concern to the members of the medical profession. But it is well to keep in mind that you have not been singled out as an isolated group charged with a failure to measure up to your collective responsibilities. On the contrary, as individuals, you have set a standard of service which entitles you to high honors. To the extent to which, however, you are asked, collectively, to consider ways and means of promoting the health of the nation you are in precisely the same position as is every other professional group and every business enterprise upon which pressure is being brought to bear, in one way or another, to conduct their private affairs in a manner that will promote the public interest.
And now let us look at the proposals which have been submitted by the Fund's staff in so far as they affect the medical profession. In so doing I will give my own understanding of these proposals and the reasons why they have seemed to me worthy of serious consideration.
First: The proposals do not constitute a health insurance plan worked out in all of its administrative and financial details. Rather they are a series of principles on which any plan, if, as, and when developed, should be based. You must have already noted the striking similarity between these principles advocated by members of our staff and the principles recently adopted by the American Medical Association, the American Dental Association, and other professional groups.
Second: The principles advocated by the staff and by organized medicine place marked emphasis on maintaining a continuing personal relationship between the doctor and his patient and, therefore, on this all-important point the proposals are calculated to maintain the status quo.
Third: There is no disagreement, so far as I am aware, on such other important points as: (1) freedom of all competent practitioners who subscribe to necessary rules of procedure to engage in insurance practice; (2) freedom of all persons to choose their physician or dentist from among all practitioners in the community who engage in insurance practice; (3) freedom of insurance practitioners to accept or reject patients; (4) no interference by the insurance system with the private purchase of medical service by those persons who can afford it; (5) separation of cash benefits from medical benefits; and (6) professional control of professional personnel and procedures.
With this brief summary of the proposals of the staff it must be clear that, instead of being conceived in a spirit of hostility to the medical profession, they are designedly intended to be positively and affirmatively helpful to the medical profession. Some of you may say that, with your intimate knowledge of how medicine should be practiced, the proposals will not be helpful but harmful to the medical profession. This is not the time or place to discuss that. My point is that one of the purposes of the staff was to make proposals that would be of benefit to the doctors.
If health insurance comes as a result of state or federal legislation, embodying the principles as to which there appears to be a general accord, it would say, in effect, to the doctors: Keep the profitable part of your practice and convert at least part of your free work into services for which you will be paid; cultivate a group of new potential patients with which you would not otherwise come in contact; do not in any way alter your personal, financial, and professional relationships with your private patients; maintain those personal relations, as far as you can, among your insured patients (and you should be able to do this as well as if not better than is now being done in much of your hospital and clinic work); and be assured that in doing all these things you are at the same time promoting the health of a vast number of people who now receive inadequate medical care or no medical care at all.
Let me hasten to anticipate at this point a comment that must be in the minds of some of you. You are saying: “Put that way it sounds all right but that is not the whole story.” You are quite right. It is not the whole story. While I believe all that I have said is true, it ignores some dangers that will have to be studied, appraised, and guarded against. There must be an avoidance of the evils of bureaucracy. There must be a freedom from political influence. There must be no repetition of the defects disclosed in the administration of the workmen's compensation laws. The spirit of self-reliance and self-respect among the insured group must be maintained. Malingering must be strictly dealt with and minimized. The risks of racketeering and chiseling should not be overlooked. All these are possible dangers that can only be appraised when a plan in all of its administrative and financial details has been worked out and submitted for critical study and analysis. But you should not wait until a plan has been completely worked out. If you do, you may be making the same mistake which I am told by my medical friends was made by the profession in respect to the workmen's compensation laws; you will be permitting others than the members of your profession to lay down the rules of the game. You will recall that the compensation laws were at first cash-benefit systems to which medical care was later tacked on. It has been difficult, I understand, to eliminate this fundamental weakness of the laws and to improve their medical provisions.
The administrative and financial aspects of the plan are quite as important as are the underlying principles. At best mistakes will be made. Some unanticipated evils will creep in. Human nature will continue to be human nature. But the answer to all this is that the ultimate goal is worth some risks if they are not too serious. Furthermore, potential new evils must be weighed not against Utopia but against existing conditions. Your leaders have voiced the general dissatisfaction with the inadequacy of the present methods of paying for medical care and with the quality of some of the medical care as given in free clinics. The advantages, both to those in need of medical care and to those who are equipped to meet that need, have seemed to me to outweigh the disadvantages provided—and this, I believe, goes to the very heart of the problem—provided the doctors themselves become wholeheartedly determined to make the plan a success.
Personally, I would have little faith in seeing achieved the full results hoped for without the cordial cooperation of the practicing physicians. Laws are not self-enforcing. To become effective they must have the support of public opinion—in this case medical opinion. Plans on paper are sterile unless vitalized by human energy. While it would be too much to expect unanimity in your profession I would hope that the predominating opinion may crystallize in favor of some plan for mutualizing the costs of medical care that would meet the needs of that vast group of our people who are neither well-to-do nor wholly destitute and who cannot, as individuals, budget their medical costs but who as members of a group can do so, and would also make provision on a more satisfactory basis than at present for the medical care of the indigent sick.
III
Next, let us put on the table the grievances directed against the Fund and with scalpel and forceps perform an exploratory operation.
If there is one complaint that stands out above all others, it is the charge of meddling by a lay group in an essentially medical problem. “No smug reformer is going to tell me how to practice medicine” has been voiced time and time again. This is a very human and natural reaction. Even the typical grandmother shows resentment at any proffer of aid as to the best way to remove the contents of an egg.
As a lawyer I would resent meddling by a lay group as to how the members of the Bar should practice law—despite the fact there is ample room for improvement. But, on the other hand, if any group, lay or otherwise, should concern itself, not with reforming the practice of the law, but with ascertaining the facts as to the number of people who suffer injustice because they cannot afford to retain a lawyer and should further concern itself with proposals of putting justice within the reach of all whose rights are infringed, without disturbing the personal, professional, or financial relationship between a lawyer and his regular clients, I would consider such proposals with no feeling of resentment. On the contrary, I would look upon such proposals with a hopeful interest, particularly if they held out the prospect of creating a body of new clients and of compensating the members of the Bar for services for which otherwise they would receive nothing.
IV
In justice to the Fund may I ask the doctors to hesitate before classifying the Fund as a wholly “lay organization.” It is true that its own technical staff includes relatively few practicing physicians. The reason for that is easily understandable. The Fund's historical approach to the subject of health has been from the angle of public health. It has never dealt with the technique of medical practice nor with curative medicine. Therefore, the senior personnel of the staff has been recruited from the ranks of those who have made a study of public health problems.
However, it should be noted that the staff does include three medical members, one of whom is a practicing physician and the other two have only recently given up their practice to do research and administrative work. In addition, among the staff ‘s collaborators, there are three other physicians who are engaged in practice. Among the seven members of our Technical Board there are four graduate physicians, two of whom are in private practice. Our Advisory Council includes twenty-three physicians among its members and many of these are eminent private practitioners.
I mention these facts not to persuade you that we are primarily a medical organization, for we are not, but merely to indicate that our Fund is constantly subject to the influence of medical points of view and of a medical understanding of the problems with which we deal.
We intend to go still further in this direction. We are in the process of forming a medical committee, which will be associated with our Advisory Council and which I hope will include members of the profession who have made a study of medical economics, to collaborate with our staff in such further studies as may be appropriate after we know the results of the conferences now pending in Washington under the auspices of the President's Committee on Economic Security.
Such studies should be made available to all groups interested in the subject of health but should not be used by those associated with our Fund to influence the opinion of the general public.
I am constrained to mention one difficulty with which we are confronted in this connection and which we have encountered on other occasions. That is the difference of opinion we find among the doctors themselves as to who should be chosen as truly representative of medical opinion on a subject of this kind. In order to satisfy the varied viewpoints it would appear that this auxiliary committee should be made up of at least one hundred doctors! We will, however, try to get a committee of workable size that will be reasonably representative.
Now that I have ventured one mild rebuke to the medical profession, may I make amends by mentioning another? Is there not some truth in the statement that part of the hostility to foundations concerned with the public aspects of health is due to the failure of the medical profession to take an active part in the public health movement during its early stages? That movement has been developed to a large extent under the auspices of non-medical organizations and that, in turn, has produced an unfortunate “group consciousness” which militates against cooperation between the two groups. I said to one of our most outspoken critics the other day that the situation reminded me of the conflicts I used to see many years ago on the western prairies between the cattle men and the sheep men. In this less picturesque day six-shooters have not yet been resorted to but the underlying thought that there is an irreconcilable conflict of interest is present. It is against this fundamental concept of divergent interests that I would earnestly dissent. I would like to have a small part in dissipating it for all time.
Our Fund must look in the future to the medical profession for advice more than it has in the past. I urge your profession not to repeat, in this matter of the public aspects of medical costs, what many of your leaders have told me was a mistaken attitude on the part of the profession at the inception of the public health movement. I know you will not forget that some of the greatest names associated with your honorable profession are those who devoted themselves to the preventive and public health aspects of medicine—Jenner, Chadwick, and Shattuck; Pasteur, Koch, and Lister; Gorgas, Trudeau, and Welch—most of them physicians and some of them well known for their skill in curative medicine. These men rank with your great healers of human suffering. Your profession can ill spare either type. Its glory lies in the fact that you have both.
In this general connection there is one other point that should not be lost sight of and that is the value which a Fund like ours can be to the medical profession, if only a basis of helpful cooperation can be established. Such a Foundation can educate the public mind by making it more health conscious, and can also educate it to place ever-increasing reliance on the medical profession as the only safe and sound agency from which to secure competent service. I believe our Fund has already been of some use in this respect. The education of the public mind on just these points was an important feature of the health demonstrations and was attended with some success. More work of this kind, and further efforts in directions that may be proposed by those of our medical advisers who are known to be “clinically minded” and which would also be helpful in promoting the health of the public, would furnish a basis for mutually helpful cooperation.
As the concept of public health has broadened it has gradually become synonymous with the health of the public, and in this relatively new aspect activities designed to promote the health of the public began to impinge upon the interests of those whose primary activity has been in the field of curative medicine.
I did not clearly understand this factor during the early process of its development. I have been vaguely aware that there must be some reason why our Fund, which was trying to keep people well, was finding itself in apparently growing discord with the doctors who were trying to make people well.
I can conceive of questions arising where the public good might conflict with the private interests of the practicing physician. Fortunately, in this matter of health insurance, there appears to me no such conflict when the true nature of the staff ‘s proposals is understood.
Such a conflict was supposed to exist in the earlier stages of the health demonstration in Cattaraugus County. It was there that the first attacks on the Fund originated and it was from that source that these attacks spread to other parts of the country. But, before that demonstration came to an end, the earlier criticisms appeared to fade away and I am told that a better feeling was established. We had no comparable experiences in the other two demonstration areas—Syracuse and the Bellevue-Yorkville District in New York. On the contrary, so far as I am aware, we had the cordial cooperation of the doctors in those areas.
V
Speaking for myself, I may say that my own interest in so-called health insurance was first aroused because of the promise it held not only to meet a public need but also to correct a grave injustice to one of the most useful, ill-paid, and imposed-upon professions in the country. Do I hear someone say: “He seems to be friendly enough but God save us from our friends”? Which brings us back to one of the purposes of my remarks this evening and that is, to make clear what the Fund's staff has proposed and, equally important, what it has not proposed.
The bogey of “State Medicine” or “Socialized Medicine,” which arises in the minds of many physicians when health insurance is mentioned, is due, in part I believe, to a misunderstanding and misinterpretation of the proposals advanced by the Fund's staff.
Health insurance, as such, does not concern itself with the technique or method of medical practice. It does not make the doctor the employee of the State. It is merely a system of paying the costs of medical care for an in-between group numerically variously estimated at millions of people through a system of group budgeting and prepayment. It is intended to be not only consistent with the private practice of medicine, but is based upon the maintenance and strengthening of private practice. Indeed, so far as the doctor is concerned, health insurance is the very antithesis of “State Medicine” because it is a system of providing funds from which to remunerate the private practitioners.
Without attempting to reconcile or to appraise the conflicting reports as to whether the British system is on the whole satisfactory to the public and to the medical profession in that country, but confining myself solely to the charge that any health insurance plan is, or would become, completely socialistic, I would ask you to read a statement in the British Medical Journal of last April to the effect that the medical profession in Great Britain regards compulsory contributory health insurance as its main bulwark against a really socialistic movement which provides medical care by means of a whole-time salaried service.
Personally, I would regard the expansion of the free clinics as fraught with much more danger to medical incomes, and to the quality of medical care, and as tending more toward State Medicine, than is involved in the type of health insurance that we are discussing. In fact, I would hope that much, if not all, of the free work now done in hospitals and clinics might be placed on a compensation basis under a well-conceived health insurance plan.
VI
There is another subject which has been frequently mentioned and which may be added to the list of complaints made against the Fund. That is the subject of propaganda. When I inquired into this matter I was told that the Fund had not been guilty of propaganda but that certain medical societies and certain medical journals had been flagrantly guilty in this respect.
My first impression was that the difference between education, which is held in high esteem, and propaganda, which is held in low esteem, might be expressed by defining education as a process of informing the public of one's own views on any given subject and by defining propaganda as a process by which your opponents inform the public as to their views on the same subject. But a little more thought convinced me that a less superficial, though still incomplete, distinction between education and propaganda would be to define education as a process of presenting the facts fairly and impartially with a strict regard for the truth irrespective of whether the truth helps or hurts the validity of one's conclusions, while propaganda is a process of presenting the facts in an intentionally biased and one-sided manner with scant regard for the truth. This disregard of the truth may be deliberate or it may be due to a lack of care in ascertaining what the truth is or to a willingness to give currency to unconfirmed rumors. In any case the effect is to mislead and confuse the public mind and to stir up unnecessary animosity.
In the last few months I have read, I believe, every article and address made by the officers and staff of the Fund on the subject of health insurance. While it is unquestionably true that the authors have reached a point in their studies where they are clearly in favor of applying the insurance principle to the hazards of sickness for the dual purpose of promoting the health of the public and of improving the financial status of those who render medical care (and to this extent their writings may be regarded as propaganda), I can find no instance where there has been a departure from the strict truth or where there has been a misrepresentation of the views of those who hold opposing opinions.
May I express the hope that my remarks this evening will be treated by the journals of the various interested professional groups, to which alone this address has been released, in the same friendly spirit, however adversely critical, that I have endeavored to show in all that I have said?
VII
Another question which has been vigorously, and sometimes hotly, debated is whether a health insurance system should be compulsory or voluntary. In considering the answer to this question bear in mind that in the proposals put forward by the staff there is no suggestion of compulsion on the doctor. The compulsion relates only to the insured person, and possibly to his employer, to set aside jointly, when earnings are not interrupted by sickness or by unemployment, a modest amount each year (little if any more than is ordinarily spent in haphazard fashion) with which to pay the costs of his medical care when sickness comes. In effect, it is a proposal to practice thrift collectively, and if so practiced the cost to many individuals is far less than if they attempted to do the same thing for themselves.
In point of fact, human nature being what it is, we all know that the majority of individuals would not voluntarily make any such provision against the rainy day of sickness and those who would be so disposed could not possibly make adequate provision out of their small incomes for anything beyond relatively trivial illness. Hence, the reason for suggesting the insurance principle that has demonstrated its value in other fields as an economical and effective protection against the hazards which menace life and property.
In this general connection it has been urged that, instead of adopting a state-wide health insurance plan, with or without a federal subsidy for those states which conform to an approved standard, it would be better to let groups within a state experiment with a variety of plans according to local preferences and local conditions. Certainly no one can reasonably object to that procedure, for all such efforts are in the right direction. I understand that some of these plans are working very well. Some doubts have been expressed as to the stability of the financial support of some of these plans and a more serious doubt as to their capacity to reach more than the fringe of those for whose benefit the more comprehensive proposals are intended. However, pending the time when the preponderant opinion among the medical profession is in favor of dealing with the problem in a more fundamental manner, I hope that experiments of this kind will be continued and multiplied.
My attention has also been called to an interesting series of proposals worked out by a medical group and which involves modernizing and perfecting present state statutes which regulate the provision for medical care for the indigent through agencies of public assistance, and also for the establishment of a system of credit agencies through which solvent persons of limited resources can meet their cost of medical care to be repaid out of their income over a reasonable period, and which also contemplates a program to educate the people as to the importance of seeking medical care from qualified physicians instead of resorting to quackery and patent medicines.
Such proposals also contemplate continuous group instruction of a technical and scientific character of the entire medical profession and an insurance system which will provide an assured income for hospitals and for those who cannot afford to meet the costs of major operations or of serious and prolonged illnesses.
The objectives of such a system are obviously desirable and, while the method and approach to their accomplishment are very different, some of them are compatible with the proposals of our staff.
Until plans embracing the administrative and financial features of each system are worked out it is, of course, impossible to make any intelligent comparison.
VIII
Despite the growing tendency of the State to engage in enterprises that heretofore have been reserved as fields for private initiative and individual development—or, to put it more accurately, because of that tendency—those of us who believe that the State exists for the benefit of the individual rather than that the individual exists for the benefit of the State are deeply concerned by the long range implications of this modern trend.
The doctors who oppose health insurance base their opposition, in part, on their fear and dislike of bureaucratic control and the injection of politics into anything so intimate and so individualistic as the practice of medicine. I share their misgivings, and, unless the plan as finally worked out can give reasonable assurances that these risks can be greatly minimized, if not wholly avoided, I would wish to proceed cautiously until it became quite clear that the advantages which appear on the face of the proposal would not be nullified by latent defects that might later develop in the administration of a plan based on such proposals.
But here again we are dealing with a factor that is not peculiar to the medical profession or to the problems which are facing it in this world of today.
The period is passing when business men were turning in desperation to the Government to save them from the devastating effect of the depression and from the consequences of their own destructive competition. The problem of cleaning up the wreckage left in the wake of the depression still remains. Hence, this tremendous and pressing problem of relief which would have been immeasurably less serious if collective thrift plans had been in operation for, say, five years prior to 1929.
Already we are beginning to hear the familiar cry of business—big and little—“Balance the budget, reduce taxation, and take the Government out of business—particularly business in which the Government competes with private industry.” To me it is a heartening cry for I have no hope for a Society made up of Government protégés.
But to my mind the best way, and in fact the only way, to take the Government out of business is for business and for gainful professions to take the incentive for providing reasonable social security away from the Government by seeing to it that the major part of the job is done by them and under their direction.
If, however, business and the gainful professions fail to provide such security, and by the same stroke afford a measure of security to capitalism, the Government will, I fear, continue to receive popular support for meeting these social needs, and the end of that road is out and out socialism.
IX
There is only one other matter of which I would speak briefly before concluding.
I would call to your attention a brief summary of certain activities of the Fund undertaken at the instance of members of the medical profession and carried out either under their direction or with their active and cordial participation.
The Fund has contributed over $250,000 toward the research work in tuberculosis at the Saranac Laboratory of the Trudeau Foundation and toward the endowment fund of that Laboratory. This work has been under the direction of Dr. Edward R. Baldwin, and many physicians specializing in tuberculosis have attended the Trudeau School and participated in these studies.
You are familiar with the work of the Diphtheria Prevention Commission in New York, which was conducted in cooperation with the five County Medical Societies of Greater New York, and which had the cordial support of the members of the medical profession throughout the City. There is ample evidence that the project not only achieved notable results but also was of material benefit to the physicians.
The Fund also contributed to the support of the National Board of Medical Examiners, with which you are familiar. As you know, this Board is made up entirely of physicians and Dr. Walter I. Bierring, President of the American Medical Association, and Dr. Merritte W. Ireland, of the Association's Council on Medical Education, are prominent members of its Executive Committee.
The Fund has derived much satisfaction from its investment in the studies in cervico-vaginitis in children, which were proposed by Dr. Walter M. Brunet, and which were carried on and continued under the direction of Doctors Van Ingen, Holden, and Hendee Smith. I am told that the report of this Committee is considered an outstanding contribution to one of the most baffling subjects with which the medical profession has to deal.
Time does not permit further references to matters of this kind but there are a number of others which have brought the Fund into helpful associations with such medical men as Doctors John R. Paul, Arthur B. Duel, William H. Park, and others. It is worthy of note that in connection with these medically conducted and Fund financed enterprises, all of which were arranged by the members of the staff and later approved by the Board of Directors, the Fund has expended upwards of $600,000 without making any allowance for the time of the staff or for other overhead expenses, whereas, in this matter of health insurance, the outlay of the Fund, apart from the time and traveling expenses of the staff and the cost of the Fund's own publications, has been so negligible that it practically amounts to nothing.
Let me end your suspense as to whether I am bereft of terminal facilities by concluding with a few words on the subject of cooperation. It is one of the most overworked words in the English language. It connotes a lovely idea that is generally lost sight of when put to the test. Too often it means, “Cooperate with me on my terms”—the sort of cooperation that occurred when the tiger returned from the ride with the lady inside and the smile on the face of the tiger.
That is not the kind of cooperation which I offer to the medical profession on behalf of the Fund and of our staff. We do not wish to swallow anyone nor do we wish to be swallowed. The Fund and the various branches of the medical profession, the public health and social welfare workers, the hospital and nursing groups, and the voluntary agencies are all interested and have their place in this broad subject of health. The field is so vast and is capable of such enormous development that there is room to spare for all of us. There is no need to step on each other's toes. There is every reason for us to go forward in orderly ranks and with irresistible power. No outside force—not even the Government—will seek to withstand our united strength if we are willing to do a good job. Our common cause will suffer only in so far as conflicts develop within our own ranks, or we fail to measure up to our responsibilities.
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No one can deny that the subject of health is affected with a public interest. No one can deny it is a gainful occupation and, therefore, affected with a private interest. The doctor who contends that the whole field of health belongs exclusively to him is on untenable ground. The medical profession would not, I assume, wish to be put in the position where it is the sole representative of the private and public aspects of such a vital subject. No one can be really comfortable when he tries to act as lawyer for several interested parties, judge and jury, simultaneously.
On the other hand, the health foundations, the public health leaders, the social workers, and the voluntary agencies who fail to guard the rightful private interests of the practicing physician are acting unwisely, are guilty of a grave injustice, and will retard their own efforts, for the reason, among others, that the family doctor, freed from financial worry and with greater opportunity to keep himself informed as to the progress in medical science, will not only continue to bring healing and comfort into the homes of his patients but will become a highly effective associate of the public health officer as well.
A recognition by the interested parties of these principles will furnish a sound basis for a cooperation that will be mutually helpful.
In this spirit I tender you our assistance and I ask for your help.