No. 3938 October 8, 1939 SOCIALIZED MEDICINE By JOSEPH M. RAY, Ph.D. Bwreau of Public School Extracurricular Activities Division of Extension PUBLISHED BY THE UNIVERSITY OF TEXAS AUSTIN Publications of The University of Texas PUBLICATIONS COMMITTEE E. J. MATHEWS J. T. PATTERSON D. CONEY A. SCHAFFER B. M. HENDRIX B. SMITH A. C. WRIGHT General Publications J. T. PATTERSON R.H. GRIFFITH LOUISE BAREKMAN A. SCHAFFER FREDERIC DUNCALF G. W. STUMBERG FREDERICK EBY A. P. WINSTON Administrative Publications E. J. MATHEWS L. L. CLICK C. F. ARROWOOD C. D. SIMMONS E. C. H. BANTEL B. SMITH The University publishes bulletins four times a month, so numbered that the first two digits of the number show the year of issue and the last two the position in the yearly series. (For example, No. 3901 is the first publication of the year 1939.) These bulletins comprise the official pub­lications of the University, publications on humanistic and scientific subjects, and bulletins issued from time to time by various divisions of the University. The following bureaus and divisions distribute publications issued by them; communications concerning publications in these fields should be addressed to The University of Texas, Austin, Texas, care of the bureau or division issuing the publica­tion: Bureau of Business Research, Bureau of Economic Geology, Bureau of Engineering Research, Bureau of In­dustrial Chemistry, Bureau of Public School Extracurric­ular Activities, and Division of Extension. Communications concerning all other publications of the University should be addressed to University Publications, The University of Texas, Austin. Additional copies of this publication may be procured from the Bureau of Public School Extracurricular Activities The University of Texas, Austin, Texas, ' at 3 5 cents per copy; In lots of ten or more, 25 cents per copy, in Texas. THE UNIVERSITY OF TEXAS PRESS ~ The University of Texas Publication No. 3938: October 8, 1939 SOCIALIZED MEDICINE By JOSEPH M. RAY, Ph.D. Bureau of Public School Extracurricular Activities Division of Extension PUBLISHIED BY THE UNIVERSITY FOUR TIMES A MONTH AND ENTERED AS •IECOND·CLASS MATTIER AT THE POST OFFICE AT AUSTIN, TEXAS, UNDIER THE ACT OF AUGUST 24, 1912 The benefits of education and of useful knowledge, generally diffused through a community, are essential to the preservation of a free covern• ment. Sam Houston Cultivated mind is the guardian genius of Democracy,and while guided and controlled by virtue, the noblest attribute of man. It is the only dictator that freemen acknowledge, and the only security which freemen desire. Mirabeau B. Lamar COPYRIGHT• 1939 BY THE BOA.RD OF REGENTS OF THE UN I VERSITY OF TEXAS TABLE OF CONTENTS PAGE Explanation and Analysis of the Question__________________________________________ 5 League Debates ----------------------------------------------------------------------------8 Affirmative Brief ---------------------------------------------------------------------------9 Negative Brief ----------------------------------------------------25 General Reading Material____________________________________________________________________ 39 The Report of the Committee on the Costs of Medical Care, 1932 ----------------------------------------------------------------------39 The Costs of Medical Care·--------------------------------------------------------42 Excerpts from the Report of the Technical Committee on Medi­cal Care to the Interdepartmental Committee to Coordinate Health and Welfare Activities, Washington, D.C., 1938____________ 47 American Medical Needs, by Hugh Cabot, M.D._______________________ 53 American Medical Association Study of Medical Care: Harris County, Texas ------------------------------------------------------------------56 Report of Survey of the Distribution of Medical Service in Texas, 1938, by Holman Taylor, M.D.________________________________ 62 Do We Have Adequate 'Medical Care in Texas? by The Editor____ 67 How Our Doctors Have Been Pushed Around, The Sage of Baltimore Unlimbers in Their Defense, by H. L. Mencken ______ 72 The Need for Reform of Medical Service in Texas, by A Texas Doctor ------------------------------------------------------------------------------------------73 The National Health Act of 1939 or the Wagner Health BilL_____ 75 Medical Care Under the Federal Farm Security Administration 76 Compulsory Health Insurance, by Hugh Cabot, M.D.___________________ 77 Medicine in Russia, by Henry E. Sigerist, M.D..____________________________ 79 The Realities of Socialize Medicine, by Henry E. Sigerist, M.D.__ 80 Group Hospitalization ------------------------------------------------------------------------86 The Texas Group Hospitalization Act of 1939, H. B. No. 19L____ 87 Group Hospitalization of Texas, Inc.________________________________________________ 91 Bryce Twitty Heads Group Hospital Service, Inc.------------------------92 Medical Service in the Texas Prison System___________________________________ 93 Texas' Children ------------------------------------------------------------------------93 Interesting Facts Taken from the 1938 Report of the Texas State Department of Health, by George W. Cox_________________ ________ 97 Interesting Facts on Public Health in Texas____________________________________ 104 Socialized Medicine Bill Proposed in Massachusetts______________________ 108 Affirmative Reading Material_______________________________________________________________ 115 Socialization of Medicine, by Ross Compton____________________________________ 115 Socialized Medicine, by Henry E. Sigerist, M.D.__ _________________________ 122 A Socialized Medicine Plan, by Henry E. Sigerist, M.D.________________ 125 Terrible Old Reactionary____________________________________________________________________ 128 A Plea for Socialized Medicine, by George W. Aspinwall ___________ 129 Socialization of Medicine, by The Medical League for Socialized Medicine ------------------------------------------------------------------------------------137 Platform or Statement of Principles and Program, by The Medical League for Socialized Medicine__________________________________ 141 PAGE Why State Medicine Is Necessary, by Edgar Sydenstricker________ 154 A State-Operated System of Medical Service for Texas, by Dan R. Davis --------------------------------------------------------------------------------------------162 Who Should Pay the Dyctor? The Group, by William Trufant Foster ----------------------------------------------------------------------------------------------166 Negative Reading Material___________________ _______________________________________________ 173 The Present Status of Texas Medicine, by E. W. Bertner, M.D.__ 173 Medicine in the Cbanging Social Order, by Irvin Abell, M.D.______ 179 The New Deal and the Socialization of Medicine, by W. B. Russ, M.D. -----------------------------------------------------------------------------------------183 The Case Against State Medicine, by Wingate M. Johnson_________ 192 Socialized Medicine Is Impractical, by William Allen Pusey, M.D. 198 Compensation Benefits for the Sick, by Sam E. Thompson, M.D. 199 We Declare War on Compulsory Sickness Insurance and Social­ ized Medicine-1935, by Holman Taylor, M.D.____________________________ 203 Principles of Medical Ethics of the American Medical Associa­ tion, 1937, Article VI.-Compensation________________________________________ 211 Medical Economics, by John H. Burleson, M.D.___________________________ 212 Socialized Medicine, by R. B. Anderson, M.D.____________________________ 219 Who Should Pay the Doctor? The Patient, by Morris Fish­bein, M.D. --------------------------------------------------------------------------------------225 Bibliography ----------------------------------------------------------------------------------------232 EXPLANATION AND ANALYSIS OF THE QUESTION The field of medical economics is a most interesting and contro­versial subject. The way of paying the doctor's bill has been chosen as a debate subject on many occasions, most notably in 1935, when it was the topic discussed by the national intercollegiate debaters. It was chosen in Texas this year by popular choice over four other subjects. The subject of medical reform was spotlighted in 1932 by the Report of the Committee on the Costs of Medical Care; and so exhaustive and decisive were the findings of that Committee that only with the Report of the President's Interdepartmental Committee to the National Health Conference in 1938 was interest revived from the lethargy into which it drifted after 1932. The question of medical care is again coming to the fore, and much reform in medical economics is inevitable. It is quite impossible for any one person or group of persons to figure out the exactly proper approach for all the high-school stu­dents of Texas to take on a given question. Each debater must study the problem thoroughly and then decide which of the many argu­ments he can present most logically and effectively. After all, de­bating is of value primarily as an intellectual exercise, and the amount of such exercise depends upon the will with which the student attacks the problem. In debating the subject of socialized medicine, the debater should not let the realistic nature of the subject lead him away from the true theoretical question to be debated; every one should try to keep the argument impersonal and on a friendly and academic plane, avoiding as much as possible any sentimentality and emotionalism. DEFINITION OF TERMS In phrasing the debate question, it was considered wise not to use the terms "socialized" or "state" medicine because of the many vary­ing interpretations given them. Let it be said at the outset, however, that there appears no valid reason why debaters should not refer to the system advocated by the affirmative as "socialized" or "state" medicine. Perhaps some will prefer to use the term "free public" medicine. The debate topic for this year is not an extreme one. On the one hand it does not go to the extreme, advocated by some, of abolishing all government medicine; and on the other it does not create a government monopoloy, crowding out all fee-for-service practice. Resolved, That Texas slwuld adopt a system of complete meiDical service available to all citizens at public expense. The word complete should not be misleading; it refers simply to the needs of all the people. Medical service: medicine includes the work of physicians in caring for the sick and promoting health. Presumably the question would cover pharmacy, dentistry, nursing, hospitalization, diagnosis, surgery and obstetrics; thus the resolution would necessarily cover these branches. As to whether chiropractors, osteopaths, Christian Science practitioners (faith healers), and midwives should be included in the resolution, it is a difficult matter to decide. Physicians them­selves do not consider such persons to be embraced by the term medicine. It would perhaps be wise for the debaters not to quibble over such matters as this, but to leave the problem to be decided by the Legislature when and if it sets up a system of socialized medi­cine, for it is after all a matter of state policy and not of definition. The word available is used advisedly in the question. If the system is made available to all, it is there for the taking, though not com­pulsory. Thus our question does not create a government monopoly of medicine; fee-for-service practice will still be permitted for those who care to pay for it. Citizens would be all those persons who are born or naturalized in the United States and who have established residence in Texas; thus it rests with the Legislature to determine what length of residence in the state establishes citizenship. It is clear, however, that transients in the state would not be citizens, whether they come from other states or from foreign countries. At Public Expense would seem to indicate a tax-supported system, but this is not necessarily true. The system might be supported as a compulsory health insurance system, with a flat-rate tax of, say, $24 yer year levied on each person. However, since many of our citizens could not pay such an assessment, the most logical assumption is that the costs of the system would be defrayed from the general revenues of the State, with whatever assistance the Federal Govern­ment might give. This would not preclude the use of contributions from philanthropists for particular medical purposes or for medical research. One or two other problems should be settled by common agreement. First the question of the relationship of the State of Texas to the government at Washington and to the county and city governments. It must be assumed that Texas could establish socialized medicine under the set-up proposed by the Wagner Health Bill, with financial aid coming from Washington. It must also be assumed that the state could require any type of cooperation from its cities and counties to put the system into practice; it could require the cities and counties to help bear the burden financially, and it could leave them broad discretion in adapting the system to local conditions. Second, we must face the question of constitutionality. For purposes of debate, it should be agreed that whatever constitutional questions might arise could be resolved in favor of the resolution; constitutional questions are interesting, but they are foreign to the main purpose of the discussion. With regard to the use of alternative arguments for the negative, a word of warning should be given. Of course, it is the duty of the affirmative to show that its proposal offers the best solution to the problem. Thus the negative will be required to prove that socialized medicine is not the best solution, and in this endeavor the negative may make use of alternatives to socialized medicine. However, if too strong dependence is placed upon alternatives, the negative will use too much of its speaking time outlining the merits of another system instead of meeting and refuting the arguments of the affirmative. ACKNOWLEDGMENTS The editor of the bulletin wishes to express his thanks and appre­ciation to the many who have helped in the preparation of the bulle­tin. Thanks are due to Dr. Holman Taylor, Secretary, and Dr. R. B. Anderson, Assistant Secretary, of the State Medical Association of Texas for the loan of invaluable materials and for many stimulating discussions of the subject. Much material also was borrowed from the Dallas Civic Federation. Professor Ross Compton of North Texas State Teachers College and Professor Dan Davis of Texas A. and M. College were kind enough to prepare special articles for the bulletin. To others at the Teachers College many thanks are due: to Bullock Hyder, debate coach, for his unflagging zeal in stimulating effort; to Gordon Carpenter of the college debate squad, whose splended work on the briefs made the task infinitely less difficult; and to Mrs. Ray for her assistance in the preparation of the manuscript. JOSEPH M. RAY. Denton, Texas, July 15, 1939. AFFIRMATIVE BRIEF Resolved, That Texas should adopt a system of complete medical service available to all citizens at public expense. I. Texas needs a system of complete medical service available to all its citizens at public expense, for A. A large portion of our populace is receiving inadequate medical care due to inability to purchase it, for 1. The depression caused serious social and economic losses which have not been overcome; incomes were reduced; many thousands were made jobless, and even yet there are many destitute families. 2. A great many of the people of Texas cannot afford to buy adequate medical and dental service. 3. About 75% of all the employed receive less than $3,000 per year. 4. About 30% of the people gainfully employed have a wage scale of less than $1,200 a year. 5. Illness is more prevalent among the poor people, be­cause a. Their monetary status denies them proper diets, sanitary conditions, and medical attention. Presi­dent Roosevelt's Interdepartmental Committee stated that better than 30% of the people were unable to purchase any medical or dental service whatever. b. The Committee on the Cost of Medical Care reported that many health defects were common among children of these families. (1) Over 65% of those examined had some serious defects. (2) 33% of those examined had defective tonsils, 34% were defective in vision, 50% had defec­tive teeth. 6. The function of deciding whether a person can pay for medical care is vested in the doctor, and sometimes a doctor will give inadequate treatment or refuse to tell the patient where he might get free treatment. Under socialized medicine everyone would know where to get free treatment. 7. It is socially undesirable to have a gradually growing class of people which sees itself cut off as indigent; a poor person or child would receive medical care free without the stigma of charity always haunting him. B. Our system of medical economics is badly out of joint, for 1. The present system is productive of many economic dis­advantages to physicians, for a. It involves an unequal distribution of income. (1) Some receive as high as $50,000 annually. (2) Others are unable to earn a living, especially when times are hard. (a) 10% of the doctors are not earning a decent living. (b) In Chicago alone in 1933 there were 400 doctors on relief. (c) Many doctors and nurses in Texas were also out of work. b. It involves an inequitable distribution of incomes, for (1) Remuneration is many times not adequate in relation to the training, skill, and responsibility required of them. (2) Physicians in rural areas with the same train­ing as specialists and city physicians cannot exact the same fee because of the economic status of the patients. 2. The present system makes for an unfair burden upon the physicians, for, a. The charitable load carried by physicians is tre­mendous. (1) The doctors located in areas most seriously affected by a depression are obligated to assume more than their just share of charity patients. (2) The most charitable doctor is imposed upon still more, thus giving more than his just share of the free medical service. b. They are forced to carry a burden of uncertain or uncollectable debts; and in hard times the income of many doctors disappears entirely. 3. Many abuses grow out of the present method of giving free service to medical charity. Many people obtain claims for free services when in reality they are not indigent sick. 4. The physician finds himself working under unfair and trying circumstances, for a. He is thrown into direct competition with quacks, faith healers, and irregular practitioners and others. (1) These groups have no code of ethics or medical restrictions, thus lowering not only the price but the standards of the medical profession. (2) Under socialized medicine quacks and patent medicines would disappear, since a real cure would be available free. b. Large overhead costs are contracted. The doctor must have private offices, expensive equipment, and so forth. c. The doctor is often unable to give the best service, for (1) Long hours make for physical weariness and fatigue; this causes carelessness and ineffi­ciency. (2) The physician may lack the facilities essential to good medical care, such as hospital, labora­tory, and X-ray equipment, all of which would be available to him at the Health Center under socialized medicine. d. There is little chance for conferences in which physicians may discuss their mutual problems. Under socialized medicine all doctors could work together. 5. People are not paying enough for public health services in comparison to other services. a. More than one-quarter of our national income is being spent each year on such luxuries as motoring, entertaining, candy, beverages, and vacations. b. Two billion dollars is being spent each year in the United States by women on beauty culture. c. Only 3.5 billion dollars is being spent each year in the United States for the costs of medical care. d. The entire investment in hospitals does not exceed 6 billion dollars. The lesson is obvious; something is radically wrong. 6. The taxpayer is paying only a small amount for public health in comparison to other services for which he has to pay. a. He is paying for health, (1) Only 1/6 as much as for fire protection. (2) " 1/7 " " " " highways. ( 3) " 1/9 " " " " police protection. (4) " 1/32 " " " " education. 7. Large portions of our population do not receive adequate medical attention because many communities have un­equal facilities for medical service. a. There is an unequal distribution of medical skill and facilities for medical service because the best talent is located, not according to the medical needs of the people, but according to localities having the most money. Many localities are thus over-supplied. b. More than half of the rural population is without even the elements of public health service. Many rural communities and even some whole counties in Texas have no hospitals or physicians. 8. An appalling situation exists on our social and economic front. There is a tragic absence of coordination be­tween the needs of the sick and the supply of medical, dental, and hospital treatment; we have medicine, doc­tors, dentists, nurses, and hospitals sufficient to give relief to the ills and pains of millions who need it, if they could only buy it. C. The cost of medical and surgical care under the present system falls heaviest on those people whose incomes are just sufficient to meet ordinary living expenses. 1. For them medicine is still in the pauper-school stage through which education passed three-quarters of a century ago. 2. To maintain their self-respect they must pay for their own medical services and also contribute to the care of those who cannot pay anything. 3. They cannot meet the severe cost of sudden illness. Illness is unpredictable and can not be budgeted for. Under our present system it often brings privation and ruin. 4. People of the middle class frequently cannot afford costly medical care, and since they are too proud to accept charity, they go without needed care. D. The cost of medical care is increasing, making it beyond the means of still additional thousands of people, for 1. New methods and processes brought about by techno­logical and scientific advancement have added greatly to the cost of medical care. These separate processes or specialization call for additional physicians and an ac­companying increase in cost. 2. Hospital service has become more and more expensive, for X-ray pictures and laboratory tests run up the cost of medical service. Although these improved facilities may prevent more deaths, the accompanying increase in cost limits this added product of science to the wealthy. E. The preventive side of medical treatment has been sadly neglected under the present system, for 1. Only $1 in $30 spent for medical care goes for preven­tive medicine. 2. "One million one hundred thousand American children die every year of preventable diseases." (Dr. Paul de Kruif) 3. The lack of preventive service is responsible for much needless illness and death. a. There are 30,000 to 100,000 cases of smallpox each year-most of them preventable. b. In 1928 there were 28,000 cases of typhoid-also, preventable. c. In 1931 more than 135,000 infants died; proper med­ical care would have saved the lives of many of them. 4. The phesent system would never be conducive to an ex­tension of preventive medicine, because a. A bounty is today placed upon sickness instead of health. Doctors make money when people are sick, -not when they are well. b. The average person may go along without knowing anything is wrong with him, and he usually feels that he cannot go to the doctor unless there is some­thing definitely wrong. Thus he must wait until the machine (his body) breaks down before he cares for it. How long would our automobiles last if we gave them fuel and ran them without checking them over until they broke down? The answer is that we take precautionary measures to prevent breakdowns. Under our present system of medical practice, the person is sick before he is checked over. II. Free medical service furnished by the state would be practical and desirable, because A. We already have many agencies which perform medical and health services free of charge. 1. Texas has a State Health Department staffed by quali­fied medical officials to cope with the problem of sanita­tion and the prevention of communicable disease. 2. Texas has, at Terrell and Austin and other places, in­stitutions for the care and cure of its citizens who are mentally defective. 3. Nearly every county and city has a Board of Health which offers medical treatment to the indigent sick. 4. Many other communities offer such services as city hos­pitals, diagnostic clinics, laboratories, public nurses, and general health services to the public schools. 5. An appreciable per cent of the medical service is today being carried by some agency of the government (c:ty, county, state, or national). a. In 1931 66% of all hospital beds in the United States were government hospitals. b. 50% of all ward cases were subsidized by New York City in 1934. This will be approximately true of many of the larger cities in Texas. c. 40% of the ambulatory cases are treated in city hospitals without charge. d. 20% of all medical costs are provided through sources other than pay patients at the present time. 6. All of the state colleges and universities of Texas furnish medical care to their students at much less than its actual cost. B. Free medical service, provided by the government for its citizens is based upon sound principles, for 1. There is no more important function of government than the prevention of disease,-the protection of the health of the people, because a. Human beings have a definite economic value. (1) $10,000 is the estimated cost required to pro­vide a moderate living for an individual up to 18 years of age. (2) A man 30 years old with $2,500 income is worth $31,000 to his family. (3) A man with $5,000 income is worth $50,000 based upon a scale of 3~ per cent interest. 2. A system of free public medicine available to all is analogous to a program of free public education, for a. Public health is as universal and vital a social prob­lem as is education. b. Public medicine would afford the same incentive for efficiency and service on the part of the physician, as public education does on the part of the teacher. 3. The Government has a definite responsibility in con­serving the health of its citizens. a. Government responsibility has long been recognized as essential in sanitation, the control of contagious diseases, the cure of tuberculosis, and so forth. b. The Government has done much in the control and prevention of disease, by (1) Providing laboratories for research and by en­couraging scientific methods. (2) Establishing agencies to prevent misrepresen­ tation and the sale of inferior medical supplies and drugs. (a) Pure food and drug and false advertising administrations. (b) United States Bureau of Weights and Measures. C. Nearly all European countries have adopted a system of spreading the cost of medical care. 1. Russia has a completely socialized system of medicine-­furnished free to the citizens and with all persons en­gaged in health activities being paid by the state. a. The Russian state holds itself responsible for the health of its citizens; it maintains their efficiency as workers and their happiness as healthy indivi­duals. b. The Soviet doctor concerns himself not merely with curing diseases, but with searching out and abolish­ing their causes-with keeping the whole community well. In other words, he is concerned with pre­ventive (prophylactic) as well as curative (thera­peutic) medicine. c. Furthermore, in Russia the citizen receives medical care according to his needs and not according to his income. d. Dr. Sigerist of the Johns Hopkins Medical School says that observation of the Russian system of medicine will give one renewed hope for the future of mankind. He states that the first great stage of medical history was curative medicine, and the sec­ond great stage will be preventive medicine. 2. Great Britain has for several years had a system of national health insurance. a. The British are proud of the system of state medi­cine finally evolved in Great Britain, and they criticize the American medical journals for mis­understanding and ridiculing it. b. "Not one in a hundred English physicians would be willing to give it up" (Dr. Anderson, Secretary of the British Medical Association). 3. In Canada some moves have been made toward socialized medicine. a. In the province of Saskatchewan, state medical service has been extended to about 150,000 persons­over one-third of the rural areas of the province. There are 107 municipal doctors in the province. b. The Committee of Economics of the Canadian Medi­cal Association, June, 1934, advocated a general sys­tem of public health service for the entire dominion. 16 The University of Texas Publication 4. Practically every European country-Germany, Italy, France, Sweden-has a system of compulsory or volun­tary health insurance. Voluntary health insurance reaches only the wealthy or the employed person. Com­pulsory health insurance is just about the same thing as socialized medicine--except that compulsory health insurance is financed by a most vicious system of taxa­tion-a fiat rate from each person regardless of the amount of property he has or of his ability to pay taxes. Furthermore, compulsory health insurance cannot pos­sibly be applied to indigents. D. Socialized Medicine would not be such a long step for the Government to take, for 1. There are now in effect many laws providing pay for the care of the sick poor. 2. The state has long taken care of the tuberculous, the mentally ill, and those afflicted with contagious diseases. 3. Examination of school children, periodic health exam­ination, prophylactic medicine, such as inoculation and vaccination, public hygiene, control of the water supply, and other health duties are now supervised by govern­ment. 4. The branches of the Military and Naval Department offer complete medical service for officers and enlisted men and their families. 5. The principle of socialized medicine is spreading throughout our institutions, for a. Practically every Texas college and university pro­vides a system of medicine for its students on a fiat rate basis; in all state-supported colleges in Texas the rate charged the students for medical and hos­pital care covers only a fraction of the cost, the remainder being paid by taxation. b. Many Texas industries, particularly the railroads, have made available to their workers a species of group medicine on a fiat rate basis. c. Complete medical service at public expense is fur­nished to all the inmates of our state institutions, such as the Blind Institute, Texas School for the Deaf, and the various prisons. 6. The recent moves toward group hospitalization in Texas constitute a marked advance toward socialization. The organization is non-profit, and therefore could very easily be taken over by the Government, thus socializ­ing a great portion of our medical service. As the system is organized now it is available only to those employed and who have a good income. 7. The Federal Farm Security Administration, in provid­ing schemes of making medical care available to needy farmers, offers another illustration of the case with which socialization could be brought about. 8. Many recent events show a trend of increasing govern­mental interest in the treatment of chronic diseases un­cared for under the fee system. a. New York State in 1935 opened a ten million dollar health and medical center, designed for the treat­ment of chronic diseases. b. The recent opening of the United States Narcotic Farms at Lexington, Kentucky, and Fort Worth, Texas, shows a determination to cure narcotic addicts as a crime prevention measure. c. Huge sums of money, federal, state, and local, are now .annually expended in caring for persons who have reached helplessness through disease. d. President Roosevelt appointed an Interdepartmental Committee to coordinate social welfare activities. This Committee reported to the National Health Con­ference in 1938, and its report served as a basis for the Wagner Health Bill which was introduced in Congress in the Spring of 1939. This bill provides for huge expenditures to be made as grants to the states to stimulate state health activity of all sorts, ranging from the dissemination of data to complete socialization by the states. The bill reflects a wide popular interest in the subject. e. Many areas are offering a vast amount of medical service free of charge. In Los Angeles County, California, "medical, dental, and pharmaceutical care, ranging from major operations to repair of false teeth," was being made available, free of charge, to the 400,000 unemployed in that section. 9. The amount of free medical service furnished by the Government is increasing each year in the United States. a. Approximately 5,000,000 families-almost 18 per cent of the families of the United States have been receiving their medical service from public funds alone; 30 per cent of the population receives free medical care. b. Today governmental hospitals comprise 28 per cent of the hospitals in the United States and contain 66 per cent of the hospital beds. In the five years preceding 1934 the growth of beds in American hos­pitals from 892,000 to 1,027,000 has come almost exclusively in government institutions. c. The number of patients in all hospitals rose during the depression. In 1929 the average daily census was 726,766. In 1933 it was 801,271. d. The number of patients in government hospitals has risen. (1) Non-government hospitals, which had an average occupancy of 64.6 per cent in 1929, had dropped to 55.3 per cent in 1933. (2) Government hospitals which had an average oc­cupancy of 88.9 per cent in 1929 jumped to 90.1 per cent in 1933. III. Free medical service furnished by the state would be a sound way of providing adequate medical care for all, because A. Certain definite benefits will accrue from such a system, for 1. It would be beneficial to the medical profession, for a. A feeling of greater financial security would exist among the physicians, doctors, surgeons, for (1) The doctor would know one month what he would receive the next. Under the present system much of his fees are in the form of credit. (2) Although in the peak year of 1929 doctors re­ceived on an average of $9,000 a year each­40 per cent of this was allotted to overhead. With the inauguration of state supported free medicine this overhead will be eliminated, be­cause doctors will not need: private offices, and secretaries. Physicians working under the new system would receive an estimated $7,000 an­nually net. (3) Their salary would come from the state-not from impoverished patients. b. The doctors would be personally benefited, for (1) They will have regularity in their work, leav­ing them definite hours for research and study. (2) Much waste and duplication would be elim­inated. (3) The burden of practice among physicians and surgeons would be more nearly equalized. (4) Carelessness, inefficiency, and fatigue, due to long hours will be eliminated, for doctors will work in shifts-thus easing the physical strain. The number of "midnight" calls, that is, when the doctor is off duty, would be reduced for each doctor. c. The standard of the medical profession as a whole will be raised, for (1) Doctors could not become careless, for their ad­vancement in the system would thereby be put into jeopardy. (2) The practice by cult healers, quacks, and ir­regular practitioners will be greatly reduced for there will be no necessity for their contin­uance--if medical service is free. (3) Doctors will be looked to as public servants­not a group of economic royalists. d. Research work would be encouraged instead of stul­tified. Doctors would have access to the best possible equipment in the laboratories. Each doctor will have more time and opportunity for research and study. This will be true because most of the discoveries and advancement in medicine have been made by men working on salaries in the laboratories or by clinicians employed on a full-time basis. 2. Certain social values would be realized under a system of free public medicine, for a. The realization by all the citizens that they may have the best of medical attention will eliminate a large amount of misery, su.ffering, and mental worry. Free public medicine would afford medical attention to those not now in a position to obtain it. This would remove the stigma of "charity" treatment. b. The general health standards would be improved, for (1) Periodic health examinations would be en­couraged. Patients would receive complete instead of partial examinations. Early recog­nition and treatment of minor ailments, would in many cases, prevent what would later develop into incurable diseases. This is especially important in regard to children's ailments and diseases. (2) Health education would be much more effective. (3) A clinical record of a large portion of the pop­ulation would be kept. ( 4) There would be no real incentive for self­treatment under socialized medicine; no one will try to treat himself when free expert advice is available. (5) Added advantage of surgery would be available when the emergency arose. These are denied many today because of the prohibitive fees. (6) Patent medicines would soon disappear, because they are attractive now only as cheap remedies. c. The shocking problem of venereal diseases could be solved. Out of the 700,000 cases of syphilis clinically recognized each year, more than one-half do not seek treatment the first year. In its primary stages when the chance for cure is the greatest only 3 per cent begin treatment. If consultative advice were free, those afflicted would go immediately to a doctor for advice. d. Under socialized medicine many unnecessary deaths would be prevented. (1) Two-thirds of the 13,000 annual deaths of women from childbirth can be prevented. In 1937 alone there were one-quarter of a million births without an attending physician being present. With free tax-supported medical care, this shocking condition could not exist. (2) One-third of the deaths caused by cancer can be avoided; cancer can be arrested if treated in time. (3) Half of the 75,000 deaths caused by tuberculosis can be eliminated if medical care is free. ( 4) Infant mortality can be cut in half. B. The cost of free public medicine would not be excessive, for 1. The cost would be more equitably distributed, because it is based upon the principle of "spreading the cost." The rich would not be "gouged," as they necessarily are under the present system to offset those who cannot pay. Doctor's bills should be paid out of the profits of health -not the losses of sickness. 2. The cost would not be as great under state medicine as under the present system. a. A great deal more than is necessary is expended because so many of the services, such as offices, office nurses, and X-ray machines are duplicated for every doctor. b. The $500,000,000 spent annually for. irregular prac­titioners, faith healers, and patent medicines will be i by the hospitals, clinics and doctors in private practice. 7. We refer patients needing hospitalization to either Hermann or Jefferson Davis Hospital. 8. No definite policy has been established but satisfactory co­operation exists between the hospitals and this agency. 9. The clinics giving medical attention outside the scope of our free antituberculosis clinic have for years given prompt attention to cases sent them by us. The Houston Tuberculosis Hospital patients are all passed on by the Houston Anti-Tuberculosis League, which acts as a "clearing house" for admission of patients to this institu­tion. 10. Florence Crittenton Home receives excellent cooperation from Jefferson Davis Hospital, Hermann Hospital, the city health labora­tories, who make laboratory tests for this agency, Texas Dental Col­lege, Junior League Clinic, Mexican Clinic, TB Clinic, Maternal Health Center and the Public Health Nursing Association. We pay Methodist Hospital a nominal fee for the delivery of the patients in our institutions. 11. Examination of school children is taken care of by the regular school medical staff. The Harris County Medical Society also has a centralizing liasion committee which arranges and provides for ex­amination of preschool children who cannot afford a private doctor. Colleges and universities.-1. Physicians and dentists assist in health examinations and health advice. 2. Medical and dental members of the college staff provide medical and dental services on a low income basis for students who require services on this basis. Pharmacists.-1. The local medical society contributes its services to the two charity hospitals-which takes care of the needy in this locality. 2. The physicians who are members of the Harris County Medical Society contribute their services to patients who are unable to pay­also service on the staff of the City-County Hospital. 3. Have always been able to find a doctor more than glad to take care of a worthy case. 4. It is taken for granted that a physician will make a call (and not one has ever refused) when an emergency exists and the patient has no money and no income. When the emergency is relieved, the patient is either continued to be treated free of charge by the physician or is sent to the City-County Hospital. Secretary.-The Medical and Dental Service Bureau, owned and operated by the members of the Harris County Medical Society, undertakes to finance medical, dental and hospital service for any one who does not wish to apply to a clinic or charity hospital. COMMENTS The number of comments which accompanied this study is so great that it is not possible to publish them all. A summarization repre­sentative of each group is given: Phyaiciana.-The number of free clinics, governmental hospitals and philanthropic organizations which provide medical care offer every one an opportunity to obtain medical care. This abundance of free services available tended to create malingering by people who could well afford to pay for medical services. The amount of free services performed by the physicians has already been given. Dentista.-The majority of the people could obtain and pay for all necessary dental services if they made a sincere effort to make ar­rangements for obtaining the services. The indigent are provided for in the free clinics and by the relief agencies. The people in the low income groups can secure good dental services at rates within their ability to pay just as easily as they obtain any other services or goods they really desire. There is need for more restorative dentistry among the low income group. Hoapitala.-In no case has there been any refusal to hospitalize patients regardless of their financial status. Welfare and relief agenciea.-There is need for additional funds to provide medical care for persons with infectious diseases, especially venereal diseases, and for persons with chronic illness who need in­stitutionalized care. Some arrangement is needed to enable relief agencies to provide medical care for transients and non-residents who are now ineligible for county aid. Health departmenta.-An increase in the county budget to provide more medical care for the indigent and persons in the low income group would solve the problem. Schoola.-School children have adequate medical care. There is need for a free dental clinic supported by public or private funds. Other organfaations.-In the Houston district 218 business estab­lishments assist and encourage their employees to become members of group hospitalization plans that are offered by insurance com­panies. Other business organizations have employees' mutual benefit associations that pay sickness and death benefits to members or mem­bers' dependents. Pharmacists.-There is adequate medical service available for the people in all income groups at fees they are able to pay. The indi­gents are provided for through the relief agencies or at free clinics. There is a great need for a filter system that will prevent the people who can afford to pay from obtaining medical care at the free clinics. Too many people go without medical care because the physicians will not help them to obtain free care. Nurses.-There is need for a medical social service filter system w determine eligibility of persons in the low income group for free care or for medical services at rates commensurate with their ability to pay. REPORT OF SURVEY OF THE DISTRIBUTION OF MEDICAL SERVICE IN TEXAS, 1938 By HOLMAN TAYLOR, M.D. Secretary, State Medi.cal Association of Texas In making the survey in question, we experienced considerable diffi­culty in the matter of engaging the interest of the medical profession of the State. There was, on the face of it, so little need for such a survey in the State of Texas, the county medical societies could not be made to appreciate the importance of the survey as a nation-wide enterprise. However, those county societies which did see the need of a survey of this character, at this time, prosecuted the same with vigor and expedition. Some of the reports were of an outstanding nature in completeness. It is believed that these reports alone will suffice to establish the facts pertaining to the distribution of medical service in this State. Participating county medical societies sent out 2,491 Forms No. 1, for the report of the physician for a period of one year. There were returned, duly accomplished, 1,045 of these questionnaires, a per­centage of 42. There are 128 county medical societies in Texas, some of them including several counties in their scope of activities. Of these, 41 participated in the survey, covering 78 of the 254 counties in the State. There are 4,526 hospital beds available to the public. No effort has been made to determine the proportion of beds reserved for special cases. The percentages would be too small. As will be noted in this report, there are 59 counties without hospitals, although there are hospitals available to practically all counties with sufficient popula­tion to require the service, as also will be noted elsewhere in this report. There are numerous small, privately-owned hospitals in the State which serve comparatively large territories. A properly con­trolled system of subsidy for small hospitals would very definitely meet the hospital needs in Texas, but it should be pointed out that the sparsely settled sections of the State do not need and could not utilize to anything like as economic extent, large and elaborately organized hospitals. It would seem that the best service that could be rendered in this connection, would be thorough equipment and support upon an adequate basis, of numerous small hospitals rather than a few large hospitals. In any instance, development of hospital service of this State should be carefully controlled and through local authorities and the medical profession locally, as set up in the National Health Program, first utilizing and expanding existing hos­pitals and sanitariums. It will be noted that there are five counties in the State with no resident practicing physician. These counties are located in sections of the State thinly populated. One not acquainted with the condi­tions in this section of the State would assume that the people in the counties mentioned are without medical attention. They are not. Physicians practicing this territory think nothing of traveling many miles in the delivery of their services. As a rule, the roads are good, and the weather rarely, if ever, interferes with such trips. The population of the counties located in this section of the State might make it appear that there are enough people to support physi­cians. The truth is, these counties are of much greater area than the average county throughout the country, and the people are so scattered that there is not sufficient concentration at any point for the support, even upon a subsidy basis, of a practicing physician. The people concerned do not understand that they are being denied medical service, and they are not. There are five counties in the State having an insufficient number of physicians, according to the standard of 2,000 people or more per physician. The remarks just made, with reference to the counties in which there are no practicing physicians, apply to this situation. It does not seem advisable to repeat. There are fifty-nine counties in the State without hospitals. As remarked above, some of these counties would appear to have a sufficient number of people to support hospitals, but either because of small centers of population and great distances between such centers, or because of hospitals near the counties concerned, there is really no deprivation in this connection. It is probably true that with modest subsidies, hospitals could be supported in some of the counties concerned, but as a rule, it is considered that no disturbing shortage of hospital facilities exists in these counties. There are counties in the list with fairly dense population, in sections of the State relatively well populated which do not have hospitals, but they in the main, are small counties with hospitals in neighboring counties. There are two counties in which there is a sort of subsidy for the support of practicing physicians. The subsidy is in the form of a salary to a county health officer, which office can be filled in Texas by a salaried official without regard to the amount of actual practice done for the county. In this State, county commissioners appoint county physicians, and pay them for service as both county physician and county health officer. It is understood that salaries are paid in the two instances named in the report in order to insure the people in each county of a practicing physician. The State of Texas does not own or operate any charity hospital at all, as such. The charity hospitals of this State are owned and operated by cities, counties, cities and counties jointly, under a special State law, and by welfare organizations of a variety, mainly churches and such religious organizations. Hospital service is ren­dered by the State in the State institutions, of course, but such service is rather restricted and mainly for the care of incidental and emergency cases. It will be noted that all State institutions for the care of wards of the State, except one, are crowded, and have waiting lists of appli­cants for admission. This is true in spite of the efforts of our Legis­lature each two years, to care for the existing situation. There is room here for a special survey, and for special effort to correct dis­crepancies in service, even though the conditions are not notoriously bad. The primary deficiency appears to be a failure to provide for specialized medical service, looking to the cure of patients, rather than to care for their incidental illnesses. This is particularly true of the penitentiary system. There is on file in the office of the State Med­ical Association of Texas, and in the office of the Penitentiary Board of the State, statistics covering a very extensive survey of medical conditions existing in the penitentiary, in the matter of physical con­dition of inmates, including both mental and physical ills. The survey was made by a committee appointed by the State Association, headed by Dr. A. C. Scott, Sr., of Temple. The personnel of the committee was of the highest, from a professional angle, and there was no charge for the service other than as to the actual expenses incurred. The State Penitentiary Board cooperated fully and enthusiastically in the work. Nothing in particular, however, came of the survey. There was some improvement in medical service, but not without a thorough reorganization, and a practically complete change in policy, could the desired results be attained. That has never happened, and won't happen so long as this service is subservient to political au­thority. Our penitentiary system comprises a central plant, where there is a fairly efficient but small hospital set-up, and a large number of farms, each farm under the complete control of a man­ager. Convicts are housed in barracks on these farms, under heavy guard. There are 7,000 inmates. There are as many as 1,500 in barracks on a single farm. To render adequate medical and sanitary service to such concentrations, under the existing conditions would be so expensive as to make the farms appear quite expensive and not, as is the case at present, productive of an income which greatly lessens the cost of prison care. This creates an economic situation hard to overcome. Medical service is rendered each farm on a contract basis, the physicians located in neighboring communities being employed on a part-time service basis. Nursing and other service rendered the sick on these farms, is by convict labor, partly trained in the system. Even this service is subject to modification at the will of the superintendent of the farm concerned. There is a physician on the State Prison Board, but he is one of nine members, and cannot control the situation except through his powers of per­suasion and his personal influence. The Health Department in Texas is well organized and functions adequately, considering the financial support it receives, which finan­cial support is relatively inadequate. Were conditions in Texas equivalent to those in the more crowded states in the country, the financial support received by the State Health Department of Texas would be ridiculously low. As it happens, most of the State of Texas is favored by climate and other conditions conducive to good health. There is a heavy incidence of malaria and hookworm, at least there has been in certain sections of the State, rather definitely outlined. It may be said to the credit of the State Board of Health and the State Health Officer, that maximum results from money appropriated for the support of the State Health Department, are attained in these as well as the more healthful sections of the State. The State Health Department, to a large extent with the support of federal funds, has for the past several years been prosecuting a rather successful educational campaign throughout the State, par­ticularly along the lines of maternal and child health, venereal dis­eases, tuberculosis, malaria, and oral and industrial hygiene, not to mention such general service as epidemiology, sanitary engineering and the like. In these enterprises the State Medical Association has joined heartily and effectively, the Association maintaining commit­tees on the several activities mentioned, which committees are directed to work in close cooperation with, and largely under the direction of the State Health Department. The State Board of Health approves of lists of physicians author­ized to treat crippled children under the crippled children law of the State. In this connection, it may be said that there is an increased disposition in the State to look upon the State Health Department as the family looks upon the family physician. The medical profession of Texas, through the State Medical Asso­ciation of Texas, has entered into an agreement with the 'Farm Security Administration of the Federal Government, through which agreement medical service is furnished clients of the Farm Security Administration. In this agreement, the State Health Department serves unofficially and without mention. Under the terms of the agreement, it will be noted that county medical societies are author­ized to enter into direct agreement with the administration, under which each family receives complete medical service for the year, in return for such funds as the families concerned are able to borrow from the administration for this purpose, regardless of the amount of money thus available, or the amount of service to be rendered. It will be noticed particularly, that this agreement does not permit the pooling of monies the clients concerned are able to borrow from the administration and the distribution of money thus pooled to the pay­ment of those who happen to require medical service. The purpose of this prohibition is frankly stated to be inhibitory of the develop­ment of a panel system of practice, such as has been found to be so objectionable from the standpoint of both the physician and his patient, wherever it is in effect. Even so, there has been a pooling of funds in certain sections of the State, for the purpose in hand. The State Medical Association has so far refrained from objecting to this practice, on the ground that such pooling of funds is by way of formation of volunteer insurance organizations under the recent agreement of the American Medical Association that subsidies through such organizations is ethically tenable, so long as they are ac­complished under the laws of the states concerned, and the patient has free choice of physician, with no intervention between the patient and his physician, either by the government or any other agency. There are said to be 50,000 farm families in the State of Texas, which are clients of the Farm Security Administration. The State Medical Association of Texas has joined the State Health Department in the support of numerous volunteer organizations look­ing to improvement of health conditions of the State, along both general and special lines, notably societies for mental hygiene, the Texas State Social Hygiene Association, the Texas Tuberculosis Association and the like. For the past two years, the State Medical Association of Texas has actively joined the State Health Department in promoting post­graduate courses for physicians, on the subject of maternal and child health, at each of which brief courses there is at least one meeting for the laity. There were forty-five such schools conducted in the State last year. On the whole, it is the opinion of the Council of Medical Economics of the State Medical Association of Texas, that medical service in Texas is the most readily available service of any to which the people have access. The medical profession of Texas, regardless of affilia­tion with the State Medical AssoCiation, is quite evidently competent, active and conscientiously engaged in both the prevention and the cure of disease. It is quite clear, from our survey and our individual and collective observations personally, that so-called "medical in­digency" does not exist in Texas to such an extent as to attract attention. Certainly the State of Texas does not furnish its pro rata share of the alleged 40,000,000 "medical needy" of the country as a whole. Accepting the definition of "medical needy" as set up by the American Medical Association, under which definition those persons are deemed "medical needy" who do not have sufficient funds to employ a physician after they have purchased other necessities of life (in judgment of local authorities), in lieu of the definition set up by the interdepartmental committee to coordinate health and wel­fare activities of the Federal Government, under which definition an income of $800 per year is the deciding factor, there may be said to be practically no "medical needy" in the State of Texas. This is true because ~he medical profession of Texas will not permit people to go unattended, if their need is made known. In this connection, it might be pointed out, that in some sections of Texas an income of $800 would be quite sufficient to supply every need of a family. It is equally true that in other sections of the State the amount mentioned would not be altogether sufficient for all needs. In this connection, it may be said that the medical profession in several large communities of the State, through county medical societies, assumes to render service to the "medical needy" in the form of clinics, in which clinics practically the entire personnel of the medical societies concerned functions, rendering the same service that the respective physicians render to their paying patients. This custom alone practically wipes out the need for the use of the term "medical needy" in this State. The subsidy anticipated by the House of Delegates of the American Medical Association for the care of the "medical needy" will find its first and most helpful application in the support of such clinics as this, including, advisably, remunera­tion for those who render the service. DO WE HAVE ADEQUATE MEDICAL CARE IN TEXAS? By THE EDITOR Most of the figures which we have on the need for medical reform apply to the United States and not to Texas alone. The editor of the bulletin communicated with the Texas State Health Department asking for information regarding health conditions in Texas and was referred to the State Medical Association of Texas at Fort Worth. Thus the only studies we have on the need for medical reform in Texas alone (see the account by Dr. Holman Taylor and the study of Harris County) were made under the direction of the American Medical Association, which had insisted for years before it conducted these surveys that there was little need for medical reform. And both of these studies reach the startling conclusion that medical care in the State of Texas and in Harris County is entirely adequate. In July, 1938, a Government committee, headed by Miss Josephine Roche, reported to the National Health Conference at Washington some interesting material on the incidence of disease in poor families. The following description of the report is taken from New R epublic.1 In families on relief, acute illness is 47 per cent more prevalent and chronic illness 87 per cent more prevalent than in families with incomes of $3,000 or more. Non-relief families with incomes of less than $1,000 have twice as much illness disability as families with more than $1,000. Infant mortality is five times as high in families with less than $500 a year as in families with $3,000 or more. Half the babies are born to families on relief or with less than $1,000. The majority of low income families do not receive adequate pre-natal care; at least half the deaths of mothers and children in the first month of life are preventable. Forty per cent of the counties in the United States, containing 17,000,000 persons, do not have a registered general hospital. About 40,000,000 persons, in families of less than $800 annual income, cannot pay for medical services and in many cases do not receive adequate care. These figures do not differ materially from those contained in the report of the Committee on the Costs of Medical Care in 1932, but in general both the studies indicated that there are grave medical needs in the United States. The State of Texas was included in both these surveys. When the pronouncements were made at the National Health Con­ference in July, 1938, the American Medical Association went on record disputing the medical needs of the Nation as outlined at the Conference. Then the American Medical Association undertook on its own hook to ascertain the medical needs of the United States. This study was conducted by an organization which has persistently claimed that the medical needs of the Nation are now being ade­quately served. One Texas doctor stated to the writer : My position is that the subject should be studied in a spirit of scientific inquiry. I resent the propagandist's methods of the American Medical Association. My conclusion is that the problemshould be studied dispassionately, particularly by observing the lGeorge Soule, "Government Fiirhts for Health," New Republic, V . 95, August 3, 1938, p. 350. experiments that have already been made in other countries and by making experiments of our own on a limited scale. I object to the persecution of men who are making worthwhile experiments. Another Texas doctor (quoted elsewhere) stated that politicians were in charge of the American Medical Association and led it into its reactionary position regarding medical reform. Officers of the Association have stated many times that they did not oppose medical reform, but in every specific case involving any kind of reform, the A.M.A. has opposed such reform root and branch. In Dallas in 1932 a group of Texas doctors entered a contract to furnish at a fixed rate medical service to the employees of the Dallas Street Rail­way Company. After protracted trials, these doctors were expelled from the Dallas County Medical Society, the State Medical Association of Texas, and the American Medical Association on charges of "unethical" practice. Notable instances in which organized medicine under the leadership of the A.M.A. has opposed group medicine of all sorts involve the Ross-Loos Clinic of Los Angeles, Dr. Michael A. Shadid's Cooperative Clinic in Elk City, Oklahoma (see his book listed in the Bibliography), and the Grolql Health Association of Washington, D.C., whose membership is taken from the employees of the Federal Home Loan Board. The Federal Horne Loan Bank Board gave its official blessing to the health insurance scheme by allotting $20,000 a year to see the system through. Members of the association if single pay $2.50 per month, and with families $3.30. The members pay two-thirds and the Government one-third of the cost. The Association plans to include dentistry in its services later on.2 The doctors involved in the Washington project were expelled from the Medical Society, had their patients excluded from private hospitals, and were so effectively hampered by the opposition of the medical organization that the Department of Justice early in 1939 initiated antitrust proceedings against the Association and the Dis­trict Society on the ground that they were restraining trade. One of the most interesting experiments in group medicine is the Milwaukee Medical Center.8 The employees of the International Harvester Company and other company employees in Milwaukee got together in April, 1936, and formed the Milwaukee Medical Center. The organization provides medical care under fiat rate prepayment arrangements with five doctors (the number of doctors has since been raised to seven). By August, 1938, the services of the Mil­waukee Medical Center had been extended to more than 6,500 people. The experiment differs from the Ross-Loos Clinics of Los Angeles, California, in that the Milwaukee Medical Center takes in individual or family memberships as well as group memberships. Rates are •see "Taxpayer Paya the Doctor.'' Na.tion's Buainess, V. 26, Nov., 1937, p. 68. 'The preaent description is taken from A. and H. Biemiller, ":Medical Rift in Milwaukee.'' Sur1lel/ Gr1111hic, V. 27, August, 1938, pp. 418-20. charged all members as follows: $1 for one person, $2 for a couple, and $3 for a family regardless of size per month. The rates must be paid six months in advance, and applicants for membership must have a physical examination before they are permitted to join. The five doctors who were originally included on the Medical Center staff were asked to resign from the County Medical Society for unethical conduct; they refused to resign and were dismissed from the Medical Society, as were also the two new doctors who were admitted to practice under the Medical Center arrangement. The Medical Society disbarment has resulted in the exclusion of the patients of all these doctors from all but two hospitals in the city. The local society was supported in its action by the A.M.A. The American Medical Association, then, did not approach its sur­veys of Texas medical needs free from bias. It has opposed all types of reform in medical economics with every resource at its command, presumably because its realizes that an admission of need anywhere will cause a leak in the dam, the leak will spread, and soon the deluge will overtake the present system of private practice. One Texas doctor told t)le writer it was his opinion that no doctor replied to the questionnaire on which the survey was based unless he was definitely in sympathy with the understood objectives of the survey. This doctor further stated that he, as a doctor, did not know or hear of people who stood in need of medical care and could not get it, since his contacts led him only to the indigents who had no income or to persons who could pay or who had made up their minds to get medical service and then beat the doctor out of his fee. He, then, as a doctor, felt that he did not know and could not be expected to know of unsatisfied medical needs in his region-that only social workers who went out among the poor and needy and investi­gated their condition could be expected to have dependable data on the adequacy of the medical care received by these people. The American Medical Association concluded its survey early in 1939, and at its St. Louis meeting in May it was announced that their conclusion was that the number of people who now did not receive adequate medical care was much nearer to forty thousand than to the forty million which was quoted at the National Health Confer­ence. Incidentally, it should be noted that both statements hedged a little. The Conference statement was that forty million people were unable to pay for medical service "and in many cases do not receive adequate care." The A.M.A. statement is that the number of med­ically needy "is much nearer to forty thousand than to forty million." The truth of the matter must be, then that there are many people who do not get adequate medical care. One does not need statistics to refute the statement that there are no persons in Texas who are medically needy; all one needs to do is to look around him to find cases of such need. A gentle reprimand was given the medical profession of Texas by the new President of The University of Tex&ll in May, 1939:' GALVESTON, May 31.-Dr. Homer Price Rainey, new presidentof The University of Texas, told graduates of the University'sMedical Branch and John Sealy College of Nursing in a commence­ment address here Wednesday night that the medical profession for both its own good and the welfare of the Nation, should study objectively the highly controversial subject of medical economics and public health. "We know that a very large percentage of our population cannot afford adequate medical care and that as a result a large per­centage of our people every year are going entirely without it," the educator said. "The result of this situation is that medical eco­nomics has now become one of the most important social issues. This issue is already well joined in American life, and, in myjudgment constitutes one of the most important problems facingthose of us who are interested in and resPonsible for medical education. "The problem of medical economics," he continued, "is so highly controversial, and the issues are so complex and so involved, that it is going to require the most effective statesmanship that we can command to resolve it satisfactorily. We cannot, however, neglect our responsibility with regard to it simply because it is contro­versial. The present situation is quite unsatisfactory, and the public is beginning to take the matter into their own hands and to work out their own solutions of these problems. The function of an educational institution in a highly controversial field such as this is not to take sides and to become propagandists, but to studythe problem objectively and scientifically so that those who formu­late public Policy may do so in the light of the best knowledge obtainable." To the question, "Do we have adequate medical care in Texas?" our only answer can be, then, that Texas is just about an average state­and whatever figures fit the United States as a whole will fit the State of Texas on a proportionate basis. If the debater can prove a need for reform of medical care in the United States, he has in effect proved such a need for the State of Texas. As a matter of fact, all medical reform will most likely come through the states as agencies. Even the National Health Bill of 1939, as proposed by Senator Wagner of New York, provides for grants of money for health pur­poses to the various states, to be used either for insurance or social­ized medicine. Incidentally, therefore, any one who argues that our socialized medicine should come from Washington and not from Austin has a very poor Point for argument; even with the Wagner Bill in effect and with federal grants of money available to the states, the question of socialization of medicine would still be for Texas to decide. Do we have adequate medical care in Texas? If you would rather believe the American Medical Association Report than the findings •Associated Presa Release. May Sl, 1939. of the Committee on Costs of Medical Care, the report of the Inter­departmental Committee to the National Health Conference, and your own powers of observing the need for such care all around you, then the answer is that we do have adequate medical care in Texas. HOW OUR DOCTORS HAVE BEEN PUSHED AROUND THE SAGE OF BALTIMORE UNLIMBERS IN THEIR DEFENSE By H.L.MENCKEN (From America's Future, Mid-Spring Issue, 1939, p. 5) When the Hon. Thurman W. Arnold, Assistant Attorney General of the United States, announced from the New Deal Kremlin that he was about to proceed against the American Medical Association as a wicked and unlawful monopoly, the project appeared to be only an elephantine sort of practical joke. . . . The present disingenuous assault upon the American Medical Association did not originate in the Department of Justice. It originated in quite other quarters and has been going on for a long while. There are doctors who aspire to office in the association, with all the honors and dignities thereto appertaining, but do not seem to be able to get the necessary votes; they appear to believe that their chances would be better under some sort of medical new deal. And there are quacks who have felt the association's heavy hand. They are against it on all counts and to the death. Both these parties have been on the war path for years. Of late they have been joined by a miscellaneous rabble of pinks, some of them outright converts to the Moscow hooey and others members of the "I'm Not a Communist-But" Association. The aim of these brethren is to nationalize the profession of medicine in the United States as it has been nationalized in Russia. Some of them say so frankly, and undertake to prove idiotically that the Russian system is better than the American. The rest, less honest, root for it without openly advocating it.... The Group Health Association, I have no doubt, is careful in selecting its medical staff; that fact is not dis­puted by opponents of its scheme.... Obviously, no doctor who works under such conditions can be said to maintain a strictly professional status. He may have a good job; he may like it, and he may give competent and conscientious service to the patients assigned to him, but in the last analysis they are the association's patients, not his. It may take them away from him at will, and assign him others. It may take them all away from him by dismissing him. They exist as his patients only by the association's grace, and on conditions that it lays down. He is no longer a free agent. He works for an association whose bosses have his livelihood, or the greater part of it, in their hands. They are tempted, in order to keep within their income from mem­bers, to work him as hard as possible, and he is tempted, as a make­weight, to abate his professional ardors, to the damage of his patients. A conscientious and industrious man may resist that temptation, but there it is, and experience with State medicine has shown that in the long run it has effects. In so far as the members save money by the scheme, the doctor loses, and the only way he can recoup is by cutting down on the service he offers .... But the chief objection to the plan, from the standpoint of the American Medical Association, is that it clearly paves the way for State medicine. Once it gets going, uplifters will arise to argue that the fees of the members ought to be paid by the taxpayers, and the first time the proposal comes to a vote it will be carried. Then all the doctors on the roll will become jobholders, and their professional labors will be largely controlled and determined by politicians. Some doctors believe that, with the New Deal reaching out constantly for more and more power, this is inevitable, and a few even profess to like the prospect. But the overwhelming majority are against it, and the American Medical Association continues to oppose it, Arnold or no Arnold. THE NEED FOR REFORM OF MEDICAL SERVICE IN TEXAS By A TEXAS DOCTOR (Letter to the Editor.) I am not one of the proponents of socialized medicine in Texas. I think I can best explain my position with a few rather simple statements. I do think that there are quite a few people in Texas who do not receive decent or satisfactory medical service because they are not able to pay for it. I, however, am not at all sure how this problem should be met. I think it is very evident that the people who do pot have any money to pay at all, who are in the indigent group, should be taken care of in Government hospitals, either local hos­pitals, county hospitals, or state hospitals. I not only think they should have their hospitalization furnished them but they should have medical service furnished them and that the doctors doing this medical service should be paid. Under the present arrangement, there are a great many people receiving medical service in the charity hospitals in Texas, in which the community supports the hospital and pays all the employees and all the expense of the hospital but no remuneration is given to the doctor. This means the time, energy, and effort the doctors spend taking care of these particular charity patients is naturally paid for by the patients who use this doctor and who pay their bills. Putting it in a more simple way, the burden of caring for the charity sick in Texas now, as far as the medical service is concerned, is paid for by other sick people in Texas, not by the well people in Texas, who could much better afford to share this burden. There is the argument on the part of some doctors that they do a decent day's work taking care of their patients who pay them; that this extra work they do in their charity clinics is additional to their usual efforts and should not be considered as being paid for by their other patients. This might be true for part of the actual time that the doctor spends; however, the fixed expenses of the doctor, his office, his automobile, his medical training, his post­graduate training, his library, and all of the other expenses, the things that he does to prepare himself to practice medicine, are shared alike by the people who pay and the people who do not; so that means that the people who pay are really paying for those who do not pay. This, I think, probably is the most important problem that we should attack first because there are many people in Texas who are not now quite able to pay for their medical service and some sort of plan should be made that they would be able to do this. If the burden of charity medicine were taken off their backs, I think it would help considerably. I am very interested in the Bill which just recently passed the Legislature in Texas arranging for voluntary hospital organizations in Texas where people of lower income groups will be able to buy hospital insurance on a group budget plan. I think this same sort of plan could be applied to their medical service. I think by far the large majority of the people in Texas are able to and could pay for their medical service if some sort of decent arrangement was made by which they could save through group budgeting. There is, however, in Texas a relatively small group of people who are on the border between these two large groups I have mentioned, who might be considered to border on indigence. I suppose it will be necessary to put them with the indigent group and furnish them their medical service without any charge whatever. I think you can see from the above that my position is not what I understand to be "socialized medicine." At the present time, there is a great deal of unrest in medical circles concerning what is going to be done with this particular problem in that they seem to be very much afraid that federal legislation is going to bring some sort of compulsory health insurance. During this particular period of unrest I think very little can be done with the medical profession. I there~ fore, feel it wise at this time not to make very many public statements regarding my opinion about the problem of socialized medicine. This does not mean that I do not have the courage of my convictions but feel it much wiser to wait until there is some time when there is a possibility of real accomplishment. I do think that the politicians who seem to have control of the American Medical Association are almost passing into what might be considered their "death struggle," and I do expect organized medicine to present a much more intelligent front in the near future. THE NATIONAL HEALTH ACT OF 1939 OR THE WAGNER HEALTH BILL Senator Wagner, of New York, introduced into the United States Senate in February, 1939, a national health bill based upon the findings of the National Health Conference and designed to supple­ment and amend the Social Security Act. The Act as introduced deals with eight major problems: 1. Maternal and child health services. 2. Services for crippled children. 3. Administration of grants to states for maternal and child welfare. 4. Public health work. 5. Grants to states for hospital and health centers. 6. Grants to states for medical care. 7. Grants to states for temporary disability compensation. 8. Rules for the determination of the financial status of states. Title 13 of the bill calls for an appropriation of $35,000,000 for grants for medical care for the fiscal year of 1940; after 1940 the Act provides no limit for grants to the state for medical care. The next highest item to be appropriated by the Act is for public health work, which carries an appropriation of $15,000,000 for 1940, $25,000,000 for 1941, and $60,000,000 for 1942. The following discussion of the Act is taken from the Journal of the American Medical Association.1 "Allotments to the several states for public health work are to be made in accordance with rules and regulations prescribed by the Surgeon General of the Public Health Service with the approval of the Secretary of the Treasury, taking into consideration (1) the population, (2) the number of individuals in need of the services, (3) the special health problems and (4) the financial resources of the state, determined as described. "Allotments to the states for hospital and health centers are to be made by the Surgeon General in accordance with rules and regu­lations prescribed by him, with the approval of the Secretary of the Treasury, which take into consideration (1) the needed hospitals and (2) the financial resources, determined as stated. 1V. 112, :March 11, 1939, p. 999. "Allotments for medical care are to be determined in accordance with rules and regulations prescribed by the Social Security Board, taking into consideration (1) the population, (2) the number of individuals in need of the services, (3) the special health problems and (4) the financial resources.... "The Wagner National Health Bill proposes to authorize grants for three purposes that are not covered by the Social Security Act: (1) to provide and maintain hospital accommodations, (2) to provide medical care and (3) to provide temporary disability compensation. "Grants are proposed under the pending bill to enable the Surgeon General to allot to the several states money to enable them to con­struct and improve governmental hospitals where needed, to assist the states for a period of three years in defraying the operating cost of added facilities, and to develop more effective measures for providing hospitals. No provision is made whereby, by grant or loan, any nongovernmental charitable hospital can be aided in making improvements or extensions or the construction of new hospitals of this class promoted. . .. "Allotments to the several states to enable them to provide medical care are to be made under authority of the Social Security Board. They are intended to extend and improve medical care, including all services and supplies necessary for the prevention, diagnosis and treatment of illness and disability, and to develop more effective measures for providing such care, including the training of personnel. These grants of federal money to the several states are to enable them to extend and improve medical care and are to be made on the basis of state plans approved by the Social Security Board. The bill is silent as to the permissible extensions and improvements of medical care that a state may make and as to whether such care shall be provided through a state medical service, similar to the public educa­tional system, or by a system of state health insurance, or by payment for services on the fee basis." MEDICAL CARE UNDER THE FEDERAL FARM SECURITY ADMINISTRATION* On October 13, 1938, the Department of Agriculture at Washington announced the approval of plans to provide emergency medical care for 77,000 Farm Security Administration clients in North and South Dakota for $2 per month. This health-insurance cooperative in the Dakotas has been furnishing medical care to some 58,000 families. The system has been managed by the Farm Security Administration for its clients, who are farmers just barely above the relief level. *Taken from "Rehearsal for State Medicine," Saturday Evenin g Post December 17 1938, p, 2.~. • • By July 1, 1939, it was estimated that 150,000 Farm Security families would be under the plan. The largest and most successful of the cooperatives is the Farmers Mutual Aid Corporation of North Dakota, extending over the whole of the State. A fee schedule of about one-third of the regular rates was agreed upon, and the Farm Security Administra­ tion paid the corporation one dollar per member. The doctors based their bills upon a basis of one-third of their regular rates and then the bills were pro-rated against the money available each month. The money will go as follows: Doctors, 51 per cent; hospitals, 37 per cent; dentists, 8 per cent; and druggists, 4 per cent. Most of the health insurance cooperatives are organized on the same basis. Free choice of doctors is permitted. This system is being extended to most other states. COMPULSORY HEALTH INSURANCE By HUGH CABOT, M.D. Author of The Doctor's Bill (From American Scholar, Vol. V, January, 1936, p, 95.) In one form or another most of the other great countries of the world have instituted some form of compulsory health insurance. Such a remedy was suggested for this country more than twenty years ago. At that time, and again within the last five years, it has met with the bitter opposition of the American Medical Association. Despite the fact, which is apparently true, that in most, if not all, of the countries where it has been instituted, medical service is more widespread than here and that there are fewer people dellied service, the opposition of the medical profession in this country has been persistent. On their side they have the undoubted fact that such insurance has nowhere worked entirely satisfactorily. In some coun­tries it has worked better than in others, but it has nowhere succeeded in delivering a first-class article. Furthermore, it stands some chance, particularly where the payments to physicians are taken over either directly by the state or indirectly through insurance companies, of handicapping the development of the practice of medicine and of more or less countenancing slipshod methods. One of the standing objections regularly voiced by physicians is that the offering of service as the result of compulsory insurance always very much increases the recorded amount of illness. . . . Any system which stands any chance of improving medical service must at the outset enormously increase the apparent incidence of illness, although the increase is obviously apparent and not real. As an objection to compulsory insurance this cannot be regarded as a respectable argument.... Furthermore, I must confess to having grave doubts of the soundness of health insurance carried out for profit.... The fact should be squarely faced that although it is possible at the present time to obtain in this country medical care which is certainly the equal and probably the superior of any service offered in the world, such service is in fact received by a relatively small part of the population. . . . It is next important to realize that it is probably not possible to set up for the whole country any system which will work satisfactorily. The size of the country, the relative density of population, the relative income of the population, ..• variations in climate . all make out of the question for us a single method such as is relatively practicable in small countries like Denmark. . . . It next seems obvious that for a large middle group of the popula­tion the distribution of costs of medical care over a term of years by some system of prepayment--Often called insurance-is the prac­ticable method. The difficulty arises in obtaining from this group contributions in sufficient numbers. The evidence tends to show that for them some modicum of compulsion will be necessary. . .. The next item should be the abandonment of the long-standing custom of expecting physicians to give their services free for the care of the indigent. . . • One obvious remedy . . . is that the public shall make up their minds to pay physicians for their services to the indigent. . . • In many of the pronouncements of organized medicine in relation to various suggested plans for so-called compulsory insurance it has been insisted that physicians should have complete control of the whole performance. This appears to me to endow physicians with knowledge and skill in the fields of economics, finance, and sociology quite beyond that which they really possess. It is my best judgment that this will involve very careful discus­sions between the representatives of three groups, all on an equal footing. Obviously the physicians must be represented, since they are in fact the qualified experts on all the medical questions involved. Next there must be the proper representatives of experts on financial and economic problems, for certainly the methods by which large sums of "new money" are to be come by cannot be satisfactorily settled by medical experts. Finally, the largely forgotten man, the consumer, above referred to as the patient, is entitled to full representation. MEDICINE IN RUSSIA By HENRY E. SIGERIST, M.D. William H. Welch Professor of the History of Medicine, The Johns Hopkins University (Excerpta from Socialized Medicine in the Soviet Union.) There is no compromise in Soviet medicine. Its idea is easy to understand because, like all other aspects of the socialist state, it is rational, logical, and clear. It seems to me that the following four points represent the most characteristic features of the Soviet health system: (1) Medical service is free and therefore available to all. (2) The prevention of disease is in the foreground of all health activities. (3) All health activities are directed by central bodies, the People's Commissariats of Health, with the result that (4) health can be planned on a large scale. We have recognized that general education is important for the welfare of a nation, that a democracy is impossible unless the popu­ lation has reached a certain educational level. The logical conse­ quence was to make education, at least elementary and secondary education, available to all, free of charge. The socialist state went one step further by declaring that the people's health is equally essential for the welfare of a nation. If a society is to function successfully, it requires healthy members. Besides, health is one of the goods of life to which man has a right. Wherever this concept prevails, the logical consequence is to :make all measures for the protection and restoration of health accessible to all, free of charge. Medicine, like education, is then no longer a trade; it becomes a public function of the state. (Pp. 86-87.) Another very characteristic feature of Soviet medicine is that it has done away with the traditional distinction between preventive and curative medicine. As a matter of fact the entire system is built upon the idea of prevention. Prophylaxis is in the foreground of all medical considerations. (P. 95.) This attitude is not surprising. It is only rational and logical. ... We all wish we could apply this principle but the social and economic structure of our countries makes it impossible. (P. 96.) One need not be a military expert to know that unity of command is essential for the success of a campaign. And yet there is not one capitalist country that has achieved unity of direction in its health work. As a result of historic and economic reasons the various health activities are subordinated to many different authorities, or there is no direction at all. (P. 98.) In June, 1918, the People's Commissariat of Health was estab­lished. For the first time in the history of medicine a central body was directing the entire health work of a nation. . The task was gigantic. The entire public health service had to be reorganized along new lines. (P. 99.) Where the entire health work of a country, preventive and curative, is controlled by a central agency, the work can be planned. This is one more characteristic feature of Soviet medicine. In capitalist countries the health work is necessarily haphazard. (P. 101.) Nobody can deny that Soviet medicine, in the short period of twenty years and under most trying circumstances, has stood the test and has created powerful measures for the protection of the people's health.... Since I have studied the Soviet Union, I know that there is a future for mankind; that whatever may happen to the Western World, there is a future for human civilization. And I know, in addition, that our highest medical ambitions are not utopian but may some day be realized. (Pp. 308--309.) THE REALITIES OF SOCIALIZED MEDICINE By HENRY E. SIGERIST (From the Atlantic M-----------------------------------­ Syphilis ---------------------------------------···­ Malaria ------------------------------------------------· Cancer of digestive tract and peritoneum..-------------------­ Cancer of uterus and other female genital organs______ ______ Cancer of the breast..___ _________ Cancer (all other ·forms) Acute rheumatic fever_ Chronic rheumatism, oeteoarthriti•---------------­ Diabetes mellitua -----------------------­ Pellagra -----------------­ Alcoholism (acute or chronic)----··-----------------------­ Progressive locomotor ataxia (tabes doraalis), general paralysis of insane Cerebral hemorrhage, cerebral embolism and thrombosis_______ Chronic rheumatic heart diseaee•----------------------------- Diseaees of coronary arteries and angina pectoris______________ Heart diseases (all other forms>---------------------------------------­ Arteriosclerosls (except coronary) , idiopathic anomalies of blood-pressure Pneumonia (all forms) . Ulcer of stomach and duodenull'.L.-.--------------­ Diarrhea and enteritis (under 2 years>-------------­ Diarrhea and enteritis (2 years and over) __ Appendicitis------------------------------------­ Hernia, intestinal obstruction_________ ____________ Cirrhosis of the liver.·-···---------·---··--··---·· --------­ Biliary calculi and otber diseases of the gall-bladder and biliary passages Nephritis -----------------------------------­ Puerperal septicemia. ---------------­ Puerperal albuminuria and eclempsia, other toxemias of pregnancy_ _ Other puerperal causes Congenital malformations.-----------------------­ Suicide .... Homicide Automobile accidents (primary) Other motor vehicle accidents_ _ Other accidents.._____ All otber causes'-----------------------­ Death 1937 1,060.4 6.4 3.5 0.8 6.9 3.9 52.9 8.1 0.9 2.1 1.5 64.9 4.6 10.6 6.8 31.7 11.4 6.0 23.8 1.1 1.1 12.6 9.4 1.9 3.2 69.3 1.5 } 45.1 123.7 9.8 86.5 5.1 31.4. 7.0 12.8 9.6 4.9 4.9 60.1 4.0 3.2 3.6 7.5 13.0 13.8 32.9 1.1 54.6 181.0 Rate (Number 1936 1,076.7 6.6 2.7 1.0 2.2 5.6 53.2 6.3 1.4 0.6 2.1 67.2 4.3 10.7 8.1 31.1 11.8 6.1 24.6 1.6 0.9 12.7 11.7 2.0 3.0 62.2 168.0 9.0 100.8 4.6 26.8 7.4 13.7 10.7 6.6 4.6 61.7 4.6 3.4 4.6 7.8 12.8 14.5 31.6 1.1 49.6 193.1 per 100,000 1936 1,014.7 8.9 2.6 1.0 3.4 7.7 39.2 7.3 1.6 0.8 1.4 64.3 4.9 10.4 10.6 29.5 11.2 5.3 22.6 1.4 1.2 11.7 10.6 1.8 3.2 64.8 152.4 8.2 83.8 4.6 29.2 8.0 14.6 10.8 5.3 6.0 58.0 6.5 3.6 4.6 7.8 11.9 14.2 29.6 1.0 48.3 181.1 F.stimated 1934 989.3 8.1 10.7 1.0 8.2 7.3 28.5 8.0 1.4 1.2 1.0 61.9 4.6 10.2 8.2 28.6 10.6 6.8 21.7 1.5 0.8 11.8 9.5 1.8 3.4 62.0 141.9 8.4 78.1 4.1 27.4 8.4 16.8 10.3 4.8 6.2 68.0 6.9 3.7 4.5 7.9 11.7 16.3 26.2 1.4 46.7 186.0 Population) 1933 983.9 9.9 9.8 1.2 6.1 10.8 43.2 7.8 1.1 0.8 0.9 66.5 6.4 9.8 7.2 28.4 11.0 6.0 20.1 1.6 1.0 11.6 11.9 1.3 3.1 69.9 132.7 7.7 65.8 4.2 31.1 10.1 14.9 10.8 4.6 4.9 57.7 6.6 3.7 4.6 7.3 12.1 16.1 21.6 1.1 44.7 187.1 ..... ~ ~ ~ ~ ~­ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ O" .,... ~· ~ .,... (;· ~ •From Vital Stat;Vtiu, Speeial 1"J>OYta. s..-...,, for T-: 11167, Department of Commerce. Bureau of the C-w--.-., A.pdl 2'1. 1N~. VoL 6, No. 60, Table D, p. 8911. NUMBER OF DEATHS UNDER 1 YEAR OF AGE FROM SELECTED CAUSES, AND DEATH RATES, BY URBAN AND RURAL AREAS, AND BY RACE: TEXAS, 1937* Cause of Death Number Other Death Rate (Number per 1,000 Live Births) Other All causes____ Measles -----­ Total 8,575 51 Urban 8,856 14 Rural 5,219 37 White 7,296 47 Negro 1,278 4 Races 2 Total 73.9 0.4 White 71.4 0.5 Negro 92.2 0.8 Races 29.9 Scarlet fever --------­-Whooping cough -------------------­Diphtheria ---------·------------­Influenza ····---····--··-·--······ Dysentery -----------······--· Erysipelas ----------------­Encephalitis (lethargic or epidemic) _____________ Meningitis (epidemic cerebrospinal) ----------­-­Tetanus ······························--------­Tuberculosis of respiratory system_______________ Tuberculosis of meninges­_____________________ Other forms of tuberculosis... -----­·------------­--­-Syphilis ·····················----·-------------------------------­Purulent infection, septicemia__________________ Malaria ······'"------­----------------------­Other infectious, parasitic diseases___________ Rickets ·----------------­Diseases of the thymus gland..----------­-----­Hemorrhagic conditions --------------­Anemias ------------------­-----­-----­Enco;ph!'l!tis (nonepidemic) -----­---­----------­Men1ng1t1s ------------------­-­--­Cerebral hemorrhage, cerebral embolism and thrombosis Convulsions ---------------------------­Diseases of ear, mastoid process____________________ _ Other diseases of nervous system and sense organs.... Diseases of circulatory system -­------­Pneumonia, all forms·---------------­---------------------­Other diseases of respiratory system............ ------------···· Diseases of buccal cavity and annexa, pharynx, tonsils Diseases of stomach.... ·-·-···············-········--··--------­Diarrhea and enteritis..........·-·-················-------­Hernia -----­·---------------------.. ---------­----------------­Intestinal obstruction -----­-----------------------­Peritonitis (cause not specified) ________________________ Other diseases of digestive system___________________ Diseases of genitourinary system_______________ Diseases of skin, cellular tissue__________________ Congenital malformations --------­--------------­Congenital debility --­---------­----------­Premature birth -----------------------­Injury at birth________________________ Other diseases of early infancy_____ External causes -­---­Unknown, ill-defined causes. All other causes.... ________··----------­ 2 285 84 850 229 14 1 12 60 27 15 5 109 8 44 32 8 39 19 11 11 46 15 68 51 7 36 1,039 91 35 98 1,585 4 69 7 13 30 21 400 410 1,891 556 231 146 369 41 1 105 11 111 44 2 1 9 8 10 10 s 63 2 9 16 1 21 5 7 4 25 4 9 23 2 15 427 88 10 23 690 1 32 1 4 11 10 162 100 876 251 89 40 39 17 1 180 28 289 185 12 3 52 17 5 2 46 6 35 16 7 18 14 4 7 21 11 59 28 5 21 612 58 25 75 895 3 37 6 9 19 11 238 310 1,015 305 142 106 330 24 2 199 30 290 200 14 1 7 47 21 14 3 69 8 83 31 7 31 18 9 11 36 13 36 44 7 29 845 78 81 81 1,453 1 54 7 12 24 16 368 342 1,613 511 194 109 263 36 36 4 60 29 5 13 6 1 2 40 11 1 1 8 1 2 io 2 32 7 7 194 13 4 17 131 3 15 1 6 5 32 68 277 45 37 37 106 5 1 (a) 2.0 0.3 3.0 2.0 0.1 (a) 0.1 0.5 0.2 0.1 (a) 0.9 0.1 0.4 0.3 0.1 0.3 0.2 0.1 0.1 0.4 0.1 0.6 0.4 0.1 0.3 9.0 0.8 0.3 0.8 13.7 (a) 0.6 0.1 0.1 0.3 0.2 3.4 3.5 16.S 4.8 2.0 1.3 3.2 0.4 (a) 1.9 0.3 2.8 2.0 0.1 (a) 0.1 0.5 0.2 0.1 (a) 0.7 0.1 0.3 0.8 0.1 0.3 0.2 0.1 0.1 0.4 0.1 0.4 0.4 0.1 0.3 8.3 0.8 0.3 0.8 14.2 (a) 0.5 0.1 0.1 0.2 0.2 3.6 3.3 15.8 5.0 1.9 1.1 2.6 0.4 2.6 0.3 4.3 2.1 0.4 0.9 0.4 0.1 0.1 2.9 0.8 0.1 0.1 O.i 0.1 0.1 0.7 0.1 2.8 0.5 0.5 14.0 0.9 0.3 1.2 9.5 0.2 1.1 0.1 0.4 0.4 2.3 4.9 20.0 3.2 2.7 2.7 7.6 0.4 14.9 14.9 ~ <:\ s·..... ~· (1:> ~ ~ (1:> ~... <:\ ~· (1:> ~ 0 -.:, *From Vital Statistics, Special RepO'l"ta, Summart1 fO'r Tezae: 1937, Department of Commerce, Bureau of the Census, Washin&'ton, April 27, 1939, Vol. 6, No. 50, Table P, p. 906. these numbers, approximately twelve per cent are of unsound mind, or mentally ill, as a result of having had syphilis. This would repre­sent .more than 1,500 patients requiring hospitalization because of syphilis, which is a preventable disease. Texas had 3,909 still births in 1936. Of this amount, 20 per cent can be attributed to syphilis, or a total of 782 preventable deaths. Mr. V. M. Ehlers of the Texas State Health Department says: There are great numbers of cases of hookworm in Texas. Studies have been made showing a very high incidence of this disease in school students coming from rural regions. There are approximately 100,000 cases of malaria recorded in Texas annually. Failure to protect our water supplies has resulted in over 300 epidemics in Texas in the last 20 years. Failure to provide sanitary drinking fountains and to wash res­taurant and soda fountain glasses well has spread trench mouth wide and handsome throughout Texas. There are eight diseases we can get from milk, water, and swim­ming pools. Swimming pools should be chlorinated, and should have in them an excess of chlorine so that not only the germs present will be killed but also those which might be brought in will be killed. We are sick twice too much in Texas. Dr. J. M. Coleman of the Texas State Health Department says: We can do away with much of this agitation for socialized medicine if we have enough money for the State Health Department's disease prevention program. The maternal mortality rate in Texas is not a question of lack of medical care, but rather a question of ignorance and carelessness on the part of mothers and prospective mothers. The United States does not compare favorably with other countries in respect to the maternal mortality rate. The rate is lowest in Holland. Until two years ago, Texas ranked 45th of all the states in the United States in this respect, although now Texas is nearing the average for the nation. SOCIALIZED MEDICINE BILL PROPOSED IN MASSACHUSETTS HOUSE NO. 351 * AN ACT to create a Department of Public Medicine and Health, which shall take over the activities of the Department of Public Health and of the Department of Mental Diseases, and certain •This bill for state medicine in lllassachusetta was introduced annually from 1929 to 1988. of the activities of the Department of Public Welfare and of the Department of Industrial Accidents. Be it enactt-d by tke Senate and House of Representatives in General Court assembled, and by tke authority of tke same, as follows: SECTION 1. There is hereby created and established a Department of Public Medicine and Health, hereinafter called the Department, for the purpose of furnishing a free and complete medical service to the people of the commonwealth of Massachusetts, patterned upon the Bureau of Medicine and Surgery of the United States Navy. SEC. 2. The Department takes over and assumes all the duties and privileges of the Department of Public Health. SEC. 3. The Department takes over and assumes all the duties and privileges of the Department of Mental Diseases. SEC. 4. The Department takes over such activities as refer to medical matters and public and private hospitals now carried on by the Department of Public Welfare. SEC. 5. The Department takes over all medical activities of the Department of Industrial Accidents. SEC. 6. The Department takes over and assumes all the activities of all local boards of health and school physicians in the common­wealth. SEC. 7. The Department shall be administered by a Commissioner of Public Medicine, who while holding this office, shall have the title of Medical Administrator of Massachusetts. He shall be assisted by a board of five other members of the medical corps as deputy com­missioners whose titles while holding this office shall be Assistant Medical Administrators of Massachusetts. SEC. 8. The Medical Administrator and the five Assistant Medical Administrators mentioned under section seven hereof shall be regis­tered physicians or surgeons of at least forty years of age. The first Medical Administrator and the first five Assistant Medical Admin­istrators to serve under this Act shall be appointed by the Governor and Council for a period of five years after the expiration of which the second and succeeding Medical Administrators and the second five and succeeding Assistant Medical Administrators shall be selected from the three highest ranks of the medical corps (senior medical directors, medical directors, and medical inspectors) in open and competitive examinations conducted under rules promulgated and established by a board of examiners appointed by the first Medical Administrator, to serve during good behavior and subject to rules of retirement hereinafter specified. Vacancies shall be filled by the holding of special examinations. SEC. 9. There shall be in the Department a Division of Physicians and Surgeons, to be known as Division A and so referred to herein­after. One of the above mentioned Assistant Medical Administrators shall be the chief of this division, the personnel of which shall comprise all registered physicians and surgeons practising in th~ commonwealth, who shall elect to accept and submit to the provisions of this Act. From among each one thousand of the personnel of this division, the first Medical Administrator shall appoint five senior medical directors, forty medical directors, and eighty medical in­spectors, total one hundred and twenty-five, one-half of whom shall serve for a term of three years and one-half for a term of six years, at the expiration of which terms their successors shall be selected from among such members of the personnel of this division as desire to compete for the position mentioned in open and competitive exam­inations conducted by the board of examiners, to serve during good behavior and subject to rules of retirement hereinafter specified. Vacancies shall be filled by the holding of special examinations. SEC. 10. There shall be in the Department a Division of Dentists to be known as Division B, and so referred to hereinafter. One of the above mentioned Assistant Medical Administrators shall be the chief of this division, the personnel of which shall comprise all registered dentists practising in the commonwealth who shall elect to accept and submit to the provisions of this Act. From among each one thousand of the personnel of this division, the first Medical Administrator shall appoint five senior dental directors, forty dental directors, and eighty dental inspectors, total one hundred and twenty-five, one-half of whom shall serve for a term of three years and one-half for the term of six years, at the expiration of which terms their successors shall be selected from among such members of the personnel of this division as desire to compete for the positions mentioned in open and competitive examinations conducted by the board of examiners, to serve during good behavior and subject to rules of retirement herein­after specified. Vacancies shall be filled by the holding of special examinations. SEC. 11. There shall be in the Department a Division of Nurses, to be known as Division C, and so referred to hereinafter. One of the above mentioned Assistant Medical Administrators shall be chief -0f this division, the personnel of which shall comprise all nurses registered in the commonwealth who shall elect to accept and submit to the provisions of this Act. From among their number the first Medical Administrator shall appoint the necessary number of super­intendents, chief nurses, and head nurses, one-half of whom shall serve for a term of two years and one-half for four years, at the ex­piration of which terms their successors shall be selected from among such members of the personnel of this division as desire to compete for the positions mentioned in open and competitive examinations conducted by the board of examiners, to serve during good behavior and subject to rules of advancement and retirement hereinafter specified. Vacancies shall be filled by the holding of special examinations. SEC. 12. There shall be in the Department a Division of Pharma­cists and Chemists, to be known as Division D, and so referred to hereinafter. One of the above mentioned Assistant Medical Admin­istrators shall be the chief of this division, the personnel of which shall be organized by the first Medical Administrator on lines similar to those established above for the personnel of Division C. SEC. 13. There shall be in the Department a Division of Tech­nicians, to be known as Division E, and so referred to hereinafter. One of the above mentioned Assistant Medical Administrators shall be the chief of this division, the personnel of which shall be organized by the first Medical Administrator on lines similar to those estab­lished above for the personnel of Division C. SEC. 14. The Department may establish or abolish such other divisions and subdivisions as it shall deem necessary or advantageous for the promotion of the purposes of this Act, and employ and dis­charge the necessary number of secretaries, clerks, and other assist­ants, subject to civil service rules. SEC. 15. The Department shall have charge of the upkeep and operation of all public hospitals and the force employed there; it shall have full supervision of all private hospitals and their employees; it shall advise and have power of supervision with respect to all questions connected with hygiene and sanitation affecting the people of the commonwealth and, to this end, shall have opportunity for necessary inspection; it shall provide for physical examinations of such citizens of the commonwealth as desire it; it shall pass upon the competency, from a professional standpoint, of all members of the personnel of the various divisions of the Department, and their promotion, by means of examinations conducted under its supervision or under forms prescribed by it; it shall have power to appoint and remove all nurses of Division C; it shall maintain and operate medical supply depots, medical laboratories, hospitals, and dispensaries; it shall require for all supplies, medicines, and instruments used by the Department; and it shall have control of the preparation, reception, storage, care, custody, transfer, and issue of all supplies of every kind used in the operation of the Department. SEC. 16. The main duty and purpose of the Department shall be to establish and maintain at all times conditions of as perfect health as it is humanly possible to attain within the population of the commonwealth through preventive measures rather than cure and for this purpose the Medical Administrator is charged with the distribution of the available personnel of the various divisions in such a manner as will most effectively and successfully accomplish said purpose. SEC. 17. The Department shall establish a set of rules governing the appointment, promotion, discharge for cause, retirement on account of age or invalidity, hours of duty, sick leave, annual vaca­tions, special vacations for study, and pensions of the personnel of its various divisions with a view to establish within the Department a perfect esprit de corps and cooperation. SEC. 18. The Department shall render free medical and surgical services of all kinds known to science in all cases of sickness, acci­dent, and childbirth, to all citizens of the commonwealth at any time when called upon including transportation to and from hospital, maintenance in hospital, and all drugs and artificial appliances and limbs, required or deemed advantageous for the speedy restoration of a sick or injured person. SEC. 19. Noncitizens of the commonwealth who accept the serv­ices of the Department shall pay for services rendered at rates estab­lished by the Medical Administrator. Such payments shall be for­warded to the treasurer of the commonwealth who shall credit same to the Department. SEC. 20. No person connected with the Department shall at any time accept a gratuity or present in payment for services rendered hereunder. Acceptance of such gratuity or present shall constitute sufficient cause for discharge. SEC. 21. The following schedule of salaries and allowances is hereby established, subject to change by the Legislature only, as remuneration of officers and personnel under this Act, with the exception of such officers and personnel as are taken over from other departments and whose pay has been already established, as follows: ALLOWANCES With Dependents Without Dependents Subsist-Subsist- Rental ence Rental ence Yearly Allow-Allow-Allow-Allow- Salary ance ance a nee anc.. Medical Administrator ---···$10,000 $1,262 $ 438 $ 960 $ 219 Assistant Medical Admr..... 8,000 1,262 438 960 219 Senior Medical Director...... 7,000 1,262 438 960 219 Senior Dental Director..... _ .. 7,000 1,262 438 960 219 Medical Director ···--···-----6,000 1,440 438 960 219 Dental Director ··--·-·············· 6,000 1,440 438 960 219 Medical Inspector ···---···-·-·-· 5,750 1,440 438 960 219 Dental Inspector ·-----·-----·--·--5,750 1,440 438 960 219 Senior Physician, base pay__ 4,100 1,440 657 960 219 Senior Dentist, base pay_ ___ 4,100 1,440 .657 960 219 Physician, base pay_······--·-·-2,600 1,200 657 720 219 Dentist, base pay_·-····--·····--· 2,600 1,200 657 720 219 Junior Physician, base pay 1,500 960 438 720 219 Junior Dentist, base pay___ 1,500 960 438 720 219 Hospital Orderlies, base pay 1,500 480 219 480 219 Dental Hygienists, base pay 1,500 480 219 480 219 Senior physicians and senior dentists are members of the medical and dental corps who have served over twenty years. Their annual salary for the twenty-first year is forty-one hundred dollars and increases by one hundred and fifty dollars each year until it reaches the maximum of fifty-six hundred dollars. Physicians and dentists are members of the medical and dental corps who have served over ten years. Their annual salary for the eleventh year is twenty-six hundred dollars and increases each year by one hundred and fifty dollars until it reaches the maximum of :forty-one hundred dollars. Junior physicians and junior dentists are members of the medical and dental corps during their first ten years of service. Their annual salary for the first year is fifteen hundred dollars and increases by one hundred dollars annually until it reaches the maximum of twenty-four hundred dollars. The base pay for hospital orderlies and dental hygienists is fifteen hundred dollars for their first year of service and increases by fifty dollars annually until it reaches the maximum of two thousand dollars. SEC. 22. The pay of the members of the nurse corps shall be as follows: During the first three years of service, eight hundred and forty dollars annually; From the beginning of the fourth year of service until completion of the sixth year of service, ten hundred and eighty dollars annually; From the beginning of the seventh year of service until completion of the ninth year of service, thirteen hundred and eighty dollars annually; From the beginning of the tenth year of service, fifteen hundred and sixty dollars annually. In addition to the above annual salaries each member of the nurse corps shall be paid the following annual allowances: rental allowance, four hundred and eighty dollars, and, subsistence allowance, two hundred and nineteen dollars. The following officers of the nurse corps shall be paid the following money allowances in addition to their annual salaries as nurses: Superintendent of nurse corps, twenty-five hundred dollars annually; Assistant superintendents, directors, and assistant directors, fifteen hundred dollars annually; Chief nurses, six hundred dollars annually. Student nurses shall receive free tuition and in addition thereto a yearly money allowance of six hundred dollars besides room and board including uniforms and their upkeep. SEC. 23. Rental allowances set forth in sections twenty-one and twenty-two do not accrue to any officer or member of the medical and dental corps and of the nurse corps who are furnished with public quarters. Otherwise the allowances as stated are to be paid in addition to the yearly salary. SEC. 24. Members of the medical and allied professions now practising in th~ commonwealth, and nurses, who shall elect to accept and submit to the provisions of this Act shall be entitled to receive such yearly salary and allowances as the number of years they have practised before the passage of this Act would have entitled them. to had this Act been in force at the time of their resignation: To illustrate: a physician who has practised in the commonwealth for fifteen full years preceding the passage of this Act shall be rated as "physician" and receive a salary of thirty-two hundred dollars for his first year of service hereunder plus allowances as set forth in section twenty-one and annual increases as stipulated. SEC. 25. In case a sufficient number of registered members of the medical and allied professions do not accept this Act within one year after its passage, the additional number needed shall be obtained by assisting students and prospective students at professional schools and colleges with an annual allowance not exceeding one thousand dollars. per year to each student who shall agree to accept this Act upon graduation. SEC. 26. All expenses incurred under this Act shall be paid from the treasury of the commonwealth. Subject to appropriation, the first Medical Administrator may expend a sum not exceeding one million dollars as preliminary expenses in establishing the organization of the Department and apprising the public thereof. SEC. 27. This Act shall take effect upon its passage. AFFIRMATIVE READING MATERIAL SOCIALIZATION OF MEDICINE By ROSS COMPTON, Professor of Sociology, North Texas State Teachers College Socialized medicine is the science and art of preventing and curing diseases through collective efforts of the public with financial support of one or more governmental units. It is the contention of this article that every person in the United States should receive the full benefit of all medical knowledge and service at the expense of the public and paid for by a system of taxation. This contention is based upon the hypothesis that the old system and philosophy of medical care has failed to meet the needs of society. Our private practice of medicine has failed to function so completely that another system of medical service is highly necessary. The general public does not receive the medical care the science of medicine is capable of rendering. This is due to the fact that medical practice is based upon the principles and philosophy of our economic order that it is a private institution and must not only work for profit but monopolize the control of medical practice in order to secure that profit. One of the fundamental principles advocated by the American Medical Association, according to the report of the Committee on Costs of Medical Care, is, "All features of medical service in any method of medical practice should be under the control of the medical profession. No other body or individual is legally or educationally qualified to exercise such control." And they have influenced legislatures in the development of such a monopoly. As a result of this philosophy and regardless of the wonderful advancement in the science of medicine, medical care is woefully inefficient. We have a splendid group of men and women trained in the science of medicine. But their administrative and economic machinery forbid a very large percentage of our people the enjoy­ment of the fruits of their scientific knowledge. When it is realized that our economic system has so poorly distributed the social income and wealth of this country that 75 per cent of our people cannot afford to pay for adequate medical service, we must recognize that a very large group of humanity is being sadly neglected. Statistics show that one out of every five applicants for the United States Navy is rejected because of bad teeth or disease of the mouth; nine out of ten school children have decayed teeth or other diseases of the mouth; more than fifty per cent of mothers who die of child birth die be­cause of deficiency of medical care; and more than half the sickness in certain congested centers of our population receive no medical care whatever. The evidence collected by the Committee on Costs of Medical Care further reveals that the services from physicians are only 43 per cent of that considered essential for adequate care; dental care, 24 per cent; and hospital care, 25 per cent. Millions of cases of sickness and disease are not permitted to be visited by a physician, examined in a clinic or nursed in a hospital. Less than seven per cent of our people have even a partial physical examination and less than five per cent are immunized against some diseases. What is worse, under our traditional medical care one small group uses the misfortunes of the many as a means of exploitation. It is estimated that at least $125,000,000 is spent annually for services of faith healers; $360,000,000 for patent medicine; while millions of men and women believe in incantations as a cure of diseases. And when we realize that out of $3,647,000,000 spent annually for medical service yet so large a proportion of our population go without medical care; and what is worse, only five per cent of the amount spent is used for prevention of diseases, we must conclude that medical service, as now practiced, is a failure. The reason medical practice is such a failure is because it is antiquated and unscientific in principle. In the American Journal of Sociology, March 25, 1933, we read the following interpretation of Dr. L. F. Barker: "A failure on the part of the medical profession to participate in trials of proposed methods of reorganization and of payment might easily be misinterpreted by the public, and a warning against too negative an attitude would seem to be in place. One need only to recall the fact that the violent opposition of medical men did not prevent the introduction of health insurance in Germany and other European countries; but it put the doctor in a false light, excited public hostility, gave rise to the idea that physicians were selfish rather than public spirited, and led to the exclusion of medical influence and leadership from the making of plans." It is equally precarious in the United States for the medical pro­fession to take the position that the institution of medicine is independent of the state. We believe that it is unsound in principle to assume the attitude as stated by the editor of the Journal of the American Medical Association: "Without the cooperation of the medical profession no system of medical practice can succeed. One listens with amusement, if not with amazement, therefore, to the threat of many of the leaders of the organizations that have been encouraging widespread propaganda for nationalization of property and socialization of personal service, when they say to the medical profession that unless it socializes itself socialization will be forced upon it. No well--0rganized body can be forced into any position." But when any one assumes the impregnable position of any organization within a state against the public will, he certainly does not understand the meaning of sovereignty. In fact the medical profession has so modified its definition of state medicine to admit of a large degree of socialized medical practice when it made the following exception to the definition of state medicine. "State medicine is hereby defined for the purpose of this resolution to be any form of medical treatment, provided, controlled, or subsidized by the federal or any state government, or municipality, excepting such services as is provided by the Army, Navy or Public Health Service, and that which is necessary for the control of communicable disease, the treatment of mental patients, the treatment of the indigent sick, and such other services as may be approved by and administered under the direction of or by a local county medical society of which it is a component part." But it is our contention that it is just as reasonable and just as possible to extend public medical service to 75 per cent of our people who are unable to pay for medical care as it is to give public service to those already recognized by the medical profession. It must be clear that the doctors are as dependent upon society as society is upon the doctors. It should be realized that the kind of medical service that we shall have must be left entirely to the will of the people. The people are sovereign. And when it is recognized that the old principles of individualism, "Laissez Faire" and profit motive, borrowed from the old economic order cannot possibly function adequately in medical service under our changed system of technology, unequal distribution of wealth, and the population movement toward the city, society will change its system of medical care. Even if the economic order were function­ ing fairly satisfactorily, medical care would still be inadequate and inefficient. This is true for it is next to impossible for a very large percentage of our families to budget for disability and sickness expenses. Its uncertainty is a vital factor in the economic problem of medical care. Even a small unexpected sickness would force 95 per cent of our people to draw upon future income, and thus involve them in debt. The average cost of medical care is about $36.00, but it is assessed so unevenly and comes so unexpectedly that it works an unbearable hardship, especially on the poor. Thus the difficulty in budgeting for sickness together with the enormous cost of sickness makes the medical system, as now practiced, a failure under any economic order. Therefore, it cannot be said that the question is not a J>roblem of medical service but economics. Again, the principle involving the right of the patient to choose his own physician is an antiquated traditional hypothesis. A rela­ tively small group of people have such a choice. If specialization were efficiently utilized and hospitalization were in reach of all the people, the question of choice of physicians would cease to exist. According to G. W. Aspinwall in the Am.ericam. Mercury, Vol. 33, 1934, over 70 per cent of the sick people have lost their privilege of selecting their doctor for the treatment of their ills due to the doc­tors own choice. Moreover, choice cannot be disassociated from interest and responsibility. The physician loses his interest and disavows his responsibility when the patient is unable to pay ade­quately for medical service. On the other hand, if the patient is able to pay, he must pay not only his own doctor bill but contribute to charitable practice. This tends to weaken the attitude of the patient toward the doctor. These conditions are enevitable in a profit motive system. Hence, we must conclude that the question of choice and interest is of little and decreasing importance. The old system of medical service is a failure from the physician's point of view. The physicians in the upper bracket probably do receive adequate compensation. But in order to secure this amount they control the supply of physicians. This prevents a large group of our people from receiving medical service. Quoting from the American Mercury, November, 1928: "I have before me a memorial address to the House of Delegates of the American Medical Associa­tion by the National Grange, petitioning the governing body of that institution to find some means to relieve the alarming and growing scarcity of country doctors." In 1909 there were 33,000 physicians in places of 1,000 population or less, in 1924 this number was reduced to 27,000, a loss of 6,000 physicians in eighteen years. The decline has continued until one-third of the towns of 1,000 or less population are now without physicians. And if this rate of decline continues, in ten more years there will be no country doctors. And it is likely to continue to decrease under the existing system for according to the Commission on Medical Education, in spite of the fact that our population is increasing the number of physicians are decreasing. Moreover, in order for them to receive adequate compensation they are forced to "rob Peter to pay Paul." Instead of a system of regulated costs of medical care, "They charge what the traffic will bear." This impels a large percentage of our people to burden them­selves in the future to pay for medical care of others. In spite of this high cost of medical service the physicians in the middle and lower brackets receive inadequate incomes. While thou­sands of people are in need of medical care many physicians have little or no work to do. And 91 per cent of our hospitals show an annual deficit. Again, if we assume the median income of $7,500 for specialists as adequate then we must conclude that the income of general practi­tioners with a median of $2,900 is quite inadequate. What is worse the median income of physicians in communities under 5,000 popula­ tion receive a net income of only $2,500. If we assumed $2,500 to be adequate, which is entirely too low, 33 per cent of all private practi­tioners receive inadequate incomes. And 12 per cent receive less than $1,000 annually. In view of these facts the middle and lower brackets of physicians are forced to turn their attention away from their profession and drift into channels of industry in order to live on a plane demanded of them. Such a condition is good neither for them, the profession, nor society. The above facts are ample proof that medical service, as now practiced, is sufficiently inefficient as to demand a change. This position is attested by the number of articles appearing in news­papers and magazines; by programs devoted to medical economics that have been offered to medical societies, congresses of innumerable lay organizations, and even the American Medical Association has been forced to defend the position of the old traditional system. But the most complete and adequate testimony comes from the report of the Committee on Costs of Medical Care, composed of fifty-four public-spirited men and women representing medical service, public health, various institutions, social sciences, and the public with Dr. Ray Lyman Wilbur as chairman, and supported by several founda­tions. After careful research and investigation this committee was convinced that the cost of medical care falls very unevenly upon different people in the same income and population groups; that our present medical system lays an unjustifiable burden upon physicians and hospitals; and at the same time gives the people of moderate incomes only a choice between recipient charity or foregoing the need of medical care. As Dr. Hamilton, Professor of La'w at Yale University and a member of the committee puts it: "The present situation is a challenge to the American people. It is not a question whether we can afford to pay for adequate and comprehensive system of medical care. A social investment in health pays its own way and yields a surplus. The present medical system is a luxury which the American nation-rich as it is in resources--is too poor to afford." The failure of the individual and profit motive system of medical service is further attested by the fact that we have been modifying the methods. Today, two per cent of medical care is paid by industry, five per cent by philanthropy, fourteen per cent by the government and seventy-nine per cent by the patient; five hundred millions of dollars were spent each year from local, state and national taxes for medical services; over ninety per cent of all hospital care for mental diseases and about the same amount for tuberculosis are public medical services; one-third of all general hospital beds are in government hospitals; extensive health departments, school sys­tems and other agencies furnish medical care in clinics and hospitals. Furthermore, we have been experimenting in group practice and social insurance. Practically all the European states, excepting Russia, who has a state system, have systems of social insurance. The first sickness insurance law was passed by Germany in 1883 which provided for a system of compulsory insurance. Other states followed in rapid succession, some compulsory and others voluntary, and also varying in methods of payment. County medical societies and other bodies of physicians have taken up the idea of sickness insurance in the United States. The California State Medical Society endorsed the principle of insurance in its application to sickness. Doctors in the Midwest and also in the East organized into groups to provide clinics and hospitals to furnish to patients in their localities for a regular payment per year. The New Jersey State Medical Society recom­mended the organization of health service in each county society for the purpose of providing by existing health agencies adequate medical care for all the people in each county at costs within their means. The Committee on Cost of Medical Care recommended a fuller plan­ning and organization of medical practice and an extensive use of the principle of insurance as a means for distributing the uneven and unpredictable costs of medical care. With all these recommendations and experiments there can be no doubt but that they are improvements over the old system of private practice. There can be no doubt that they are beneficial to all who are able and do participate for they not only provide more adequate facilities but help to distribute the cost of medical service. It has been pointed out by Dr. Corwin, Director of the Hospital Service Bureau of the United States Fund of New York that whatever de­ficiency may have existed in the various European schemes it can not be blamed on bad organizations, inertia of doctors, or a failure to appreciate the importance of preventive medicine, but to the in­ability to raise sufficient funds to provide adequate service. It is not a question of comparing the efficiency of medical group practice and social insurance with the old private practice. Group practice and insurance are supplementary to private practice. They are merely aids to a broken-down system. And to whatever extent they facilitate and equalize medical costs they are beneficial. But they cannot solve the problem of medical service because they cannot include all the people; neither can they have the proper control. They are only phases of socialization and not complete socialized medicine. Public health service, state administered and tax supported is the best solution to the problem of medical care. This is true because medical service is a social function. It is to the best interests of society that its members be kept in as good health as possible. The report of the Committee on Costs of Medical Care revealed that 250,000,000 working days were lost in 1929 because of sickness. And while the public spent $3,650,000,000 for medical care, the estimated cost of sickness in America annually is $10,000,000,000. But the most serious effect of inefficient medical service is its influence on personality maladjustment. A sick or disabled person is unable to play the necessary social role in society and thus becomes maladjusted and a social problem. It is to the interest of society that its mem­bers be kept physically and mentally well and that they be properly adjusted as to be able to play a normal and efficient role in the social organization of society-that they may be good citizens. With a realization that the science of medicine has developed a relatively high degree of efficiency and yet only 5 per cent of the total amount spent for medicine under private practice is devoted to prevention of sickness, and that 70 per cent of our people are unable to pay for medical service, it must be evident that free medical service could better solve our problem. When society recognizes that the institution of medicine is not and cannot be a private affair to procure a profit for a few at the expense of the many, but that its primary function is to keep the members of society fit for duty, the objection to free medical care will cease to exist. In the second pleace, public medical service is preferable because under the system the cost of medical service will be equally dis­tributed. Though the expense of $36.00 per person per year, coming at irregular and uncertain intervals, is too costly for 70 per cent of our population, the total cost of adequate care would constitute no serious burden when levied against the financial resources of our country. This is attested by the fact that this cost constitutes but 4 per cent of our national income. It is our contention that the state can afford to spend 4 per cent of its annual income on free medical service in order to keep its mem­bers as sound as possible in body and mind. It will be not a liability but an asset. Finally, state medicine will be more efficient. Public medical serv­ice not only cares for all the people and equably distributes its cost, but it will be more effectively administered. There will be not only more clinics, hospitals, nurses, and physicians but they will be more equably distributed; it will insure more regularity of service, enhance incomes, promotion on the basis of accomplishments, opportunity to study and specialize, and physicians can devote more time to their profession. There will be no occasion for bartering, bargaining, and splitting of fees; no reason for a few physicians to be overworked while others have nothing to do. This is true because there will be a better organized cooperative method of providing efficient, scientific medical advice free to all the people and at a lower social cost. This efficiency is attested by facts of experience. According to Dr. Haigh, North, American Review, February, 1929. "Most contributions to the advancement of medicine have emanated from clinics, labora­tories, and institutes manned by salaried personnel working together." The high professional standing in the army and navy, as well as colleges has been acknowledged by the American Medical Association to be above that of civilians in general. The growth and development of state medicine is also proof of its efficiency. The various methods of group medicine, group and social insurance, workmen's compensation, expansion of governmental health service, governmental provision for hospitalization are all trends toward state medicine. Seventy per cent of hospital care is now under the control of the state. According to P. H. Fesler: "Without being pessimistic as to the future, the American Hospital Association would be unmindful of the member's interests if it did not recognize the possible breakdown of the voluntary hospital system in America." The rapid development of the various public welfare agencies reveal that private practice in medicine must give way to governmental control. Medical care of indigents is a recognized responsibility of government. And the effect of the depression has been to greatly increase this number. Medical service, being a social institution whose function is to guard the life and health of all the people, must, like the public education, become a compulsory process. This can be accomplished only under a state system of medicine. It is the state's business to educate its physicians and nurses, to provide for cilinics and hospitals for all the people. Physicians and nurses, like teachers and social workers, are expected to do social service work, not primarily for profit, but in the interest of humanity. And if human resources are to be conserved, the state must not only have adequate facilities, but also a compulsory process of both prevention of disease and ill health, as well as an opportunity for curing the diseased persons. This can be achieved only under a state system of medicine. SOCIALIZED MEDICINE By HENRY E. SIGERIST, M.D., Jokns Hopk:i,ns University (From Yale Review, Vol. XXVII, March, 1938, pp. 477--481.) I know what the traditional objections to socialized medicine are. We frequently hear that such a system would lead to "regimentation," while the word that applies to it is "organization." Why should anybody feel regimented by having the possibility to budget the cost of illness and by having the privilege to receive all the medical care he needs. We do not feel regimented when we send our children to school, or when we appeal to a court to protect our rights and our honor, or when we call on a minister of the church for advice without paying him a fee. Nobody would be compelled to seek treatment, and if a man particularly enjoyed his arthritis he would retain the liberty of having it. Conditions are different in the case of communicable diseases where a sick man is a direct menace to his environment. This has been recognized long ago, and society has made provisions to isolate as much as possible the contaminated individual. In several countries, the spreading of venereal diseases is considered a criminal offense and is prosecuted by law. There is a duty to health because the sick man is useless to society and often a burden, but is a moral, not a legal obligation. Gradually we come to recognize that health is much more than the absence of disease, that it is something posi­tive, a joyful attitude towards life. Another objection frequently heard is that doctors, if they were salaried and had not the incentive of making money, would neglect their duties. I think that such an assumption is an insult to the medical profession, and it is very queer that this objection is fre­quently made by medical organizations. The Code of Ethics of the American Medical Association explicitly states that "a profession has for its prime object the service it can render to humanity; reward or financial gain should be a subordinate consideration." Can a doctor wish for more than to be given complete social security and to be able to devote all his time and all his energy to his patients without being obstructed by economic barriers? I have not been in practice for a long time, but for seventeen years I have helped to train physicians and I have kept in close touch with many of my former students, who are now practicing in cities and in rural districts. More than once they have come to see me in despair because they were unable to practice the type of medicine they had been taught. Economic con­siderations compelled them to lower their standard and to compromise. Every young doctor knows of such conflicts, and many of the best minds go into public health service because they refuse to be dragged into business. If a man's ambition is to become rich, he should not enter the medical career--one of the most harassing professions, in which very few people ever become wealthy. Thousands of doctors work on salaries at present, and nobody can deny that they are doing a good job. And whenever a position is vacant, hundreds apply for it, so that the idea of being salaried cannot be quite unattractive. Under socialized medicine, there would be plenty of incentive for the doctor. He could rise to positions of greater responsibility, and his income would increase accordingly. Many people are afraid that under socialized medicine the free choice of a physician would be somewhat limited. They insist that everybody should be able to select the one doctor in whom he has greatest confidence. There can be no doubt that confidence is an essential factor in the relation of doctor to patient. The elder Seneca said: "Nihil magis aegris prodest quam ab eo curari a quo volunt"­Nothing is more advantageous to invalids than to be cared for by the person they wish. We must not forget, however, that our present system allows only very few people to choose their own doctor. The dispensary patient has to accept whatever doctor happens to be there. In most rural districts, only one or possibly two physicians are avail­able so that the patient has practically no choice; and even those patients who in the cities could make a wide selection very often call on the neighborhood doctor whoever he may be. It is very difficult for a layman to pass judgment on the competence of a physician. If medicine were socialized, the free choice of a doctor would p03Sibly be somewhat more limited than it is today, but the physicians being members of an organization would be under a certain control. They would have ample opportunities for postgraduate training, and in­competent elements could be eliminated-which is practically impos­sible today. Medical science, moreover, has progressed so much and has developed so many objective methods of examination, and the general standard of the medical profession, on the other hand, has been raised so considerably in the last decades that a man need not be a genius to be a competent doctor. Everybody agrees that the personal relationship between physician and patient must be preserved. The patient does not want to consult a committee when he is in trouble, nor can medicine be practised by a corporation. The patient will always call on one doctor and open up his heart to him, but the fact that this doctor is a member of an organized group from which he can seek help and advice does not spoil the relationship. What spoils it today is that the doctor has to charge a fee for each individual service and that the patient has to pay the bill. Once the money question is removed, the relationship between physician and patient becomes purely human. The value of a commodity can be estimated pretty accurately, while it is humanly impossible to estimate the value of a medical service in dollars and cents. Advice given by a doctor in a half hour's conversation may have tremendous repercussions in a man's life, while a major opera­tion may be entirely worthless. If we remove the doctor from the economic struggle, we set him free and allow him to practice what medical science has taught him. It is not enough to provide medical care for everybody. Not only the quantity but also the quality of service matters a great deal. Many people fear that socialized medicine would lower the standards by developing a certain routine. I cannot share these apprehensions. If we look around today we soon find that the quality of service given to most people is rather inferior, to put it mildly. Necessary exami­nations and treatments are not made because the patient cannot afford them. Post-graduate medical education is in its infancy. The highest type of service is given in hospitals, wherever the doctors are members of organized groups. This, however, is just what socialized medicine tends to develop. It endeavors to bridge the gap that exists today between individual and hospital practice by bringing the gen­eral practitioner into close contact with a health center. The most serious objection to socialization of medicine in America is that government control would necessarily bring politics into the medical field. Political corruption has been observed more than once in the past, and it obviously would be a catastrophe if appointments were made not according to merit but according to political considera­tions. The whole system would be wrecked if entire staffs were dis­missed and replaced whenever a new party came into power. Corrup­tion may occur in certain government activities, but this does not mean that graft and administration are one. Political interference can be opposed by public opinion, and, as a matter of fact, has been opposed successfully more than once. Nobody can deny that our United States Public Health Service is clean and most competently and efficiently administered. More than one State and city have suc­ceeded in keeping their health departments free of politics. In the period of transition in which we are living, government will have to take over many functions of society that could not be performed otherwise, and if the country wishes to progress in an evolutionary rather than in a revolutionary way it will by necessity have to amend its political manners. Graft and corruption discredit the democratic form of government and pave the way to fascism. To fight them relentlessly is to fight for the cause of democracy. The average citizen is not vitally interested in the construction of highways and bridges, but he is highly concerned about his and his family's health. Political corruption in the medical field would not be tolerated; it would be opposed by public opinion in the strongest possible way. It is, therefore, quite conceivable that the socialization of medicine would not only bring health to the people but also improve our political conditions. A SOCIALIZED MEDICINE PLAN By HENRY E. SIGERIST, M.D., Johns Hopkins University (From Yale Review, Vol. XXVII, March, 1938, pp. 468-471.) Let us be utopian for a moment--knowing that more than once utopian ideas have become reality-and let us visualize an ideal medical system, a system that would allow us to utilize all the present resources of medical science. Everybody agrees that such a system must emphasize the preventive aspect of medicine. Every child knows that prevention is better than cure, and yet of every thiry dollars spent for medical care today, only one is spent in prevention and twenty-nine go for cure--one more evidence that the present system is unable to provide medical service in a sensible way. What, then, would the ideal plan be? Let us take an administrative district as an example, a county, or a group of smaller counties. The first concern would be to establish a health center consisting of a hospital, dispensary, tuberculosis sta­tion, anti-venereal station, pre-natal, maternity, and infant welfare station, bureau of physical education, bureau of health propaganda, laboratories, public health department, and whatever special institu­tion the local conditions might require. An industrial region would call for a division for the prevention and treatment of industrial accidents and diseases. A malarian region would require other special provisions. The health center would be staffed with physicians representing all specialties, with public health officers, scientists, dentists, pharmacists, nurses, public health nurses, social workers, and technicians. It would be an organic medical unit, working as a. team, ready to give complete medical service, preventive, diagnostic, and curative. Its functions would be to protect the health of the inhabitants of the district by applying all the weapons that medical science has forged. The director of the center would be the chief medical officer of the district, responsible for the people's health and accountable for it to the Health Department of the State. Members of the health center, general practitioners, would be placed in the various towns, as outposts of the center. There should be at least two working together, an experienced practitioner and a. youngeI man. There should be at least two, not only to increase the efficienc;y of the service but also to allow the individual doctor to have regula1 vacations, to attend post-graduate courses at regular intervals, anc to do clinical work in the center from time to time. These doctors, aided by nurses and technicians, would form th1 local health station, the branch unit of the center. They would worl in close cooperation with the center, referring difficult cases to it fo1 examination, sending in patients to be hospitalized, receiving th1 specialists' help and advice whenever required. One of their mos important functions would be to survey the health conditions of thei: region. They would find in one family that the mother had died o: tuberculosis and that the children were menaced. Such a famil: would have to be wat'ched very carefully. Its living conditions migh . have to be improved. The children would have to be examine' . regularly, and provisions made to have them spend their vacations in healthy environments, in the mountains or on the seashore. In another family the doctors would find that the father had died of arteriosclerosis, his brother of nephritis. They would know what the weak spot of this family was, and in what direction they would have to concentrate their attention. Another function of the local doctors would be to enlighten the population in matters of health. They would organize a committee of citizens with which they could discuss the local health problems and on whose cooperation they could rely. They would also take the initiative in organizing a nursery, playgrounds for children, physical culture clubs, and similar institutions. And whatever they under­ took they would always feel that they were strongly backed by the health center. Regular conferences would bring the doctors together and give them a chance to discuss their experiences. In the cities, health centers would be established in the various districts and in the larger enterprises, where the workers would be given entrance and periodic examinations, not in order to determine whether they should be employed or not, but in order to find out for what occupation they are best fitted. In a highly differentiated society like ours, there is a job for nearly every physical condition and grade of intelligence. Sanatoria for the treatment of tuberculosis, hospitals and labor colonies for mental patients, and health resorts for the treatment of chronic diseases would be established at strategic points and would receive the patients assigned to them by the various health centers. Under such a scheme the central health authorities, state and federal, would have a great task to fulfill. They would be responsible for the people's health. They would issue policies, would coordinate the efforts of the various local groups, would encourage research and work out methods for the application of the results of research on a nation-wide scale. If medical care is to be available to all, it must be free of charge like education. Physicians and other medical personnel would re­ceive salaries, the amount of which would be determined by experience and responsibility. I think there is no need to go into further details. Sketchy as this outline is, it has made clear what type of medicine I have in mind. It is socialized medicine, a system under which medical care is not sold to the population or given as a matter of charity. Medical care, under such a system has become a function of the state, a public service, to which every citizen is entitled. It is a system that allows the practice of preventive medicine on a large scale and makes it possible to apply all resources of medical science unrestrictedly. Such a system may seem utopian, but it is not. It actually is in operation in one-sixth of the inhabited earth, in the Soviet Union. Russia was the first country to establish a complete system of social­ized medicine and did it under incredible difficulties, when the country was almost totally wrecked. In 1918 the Commissariat of Public Health was established and the work of construction began sys­tematically. Hospitals, sanatoria, health centers were erected all over the country. New medical industries had to be created. The number of physicians was increased five times. New medical schools and news schools for the training of nurses and other personnel were built. The guiding principle of Soviet medicine is to create the best possible working and living conditions, to provide the best facilities for rest and recreation, and to protect people medically from the moment of conception to the moment of death. TERRIBLE OLD REACTIONARY (From Time, May 16, 1989, p. 89.) A successful surgeon with his own private practice is Professor Bertram Bernheim of Johns Hopkins. But he does not have much faith in the United States system of private medical care. He sees the public asking for more adequate, low-cost medical service, sees national health insurance coming, and he wants his colleagues to prepare for the future, lest laymen take over "the big business of medicine." This week in a startling book, Medicine at the Crossroads (Morrow, $2.50), with a warp of drastic criticism and a moderate woof of diplomacy, Dr. Bernheim ripped into the medical profession. Con­sidering himself a "terrible old reactionary," he offered plans for medicine's modernization. Among his suggestions: Surgery. Americans, says Dr. Bernheim, are "hell-bent for sur­gery" because it is dramatic and thorough. Although there are hundreds of outstanding surgeons who never rush into an operation, "too much surgery is done." Reason: Surgery "is easy money-it comes quick and there's lots of it." While family physicians, who suggest operations, are paid very small fees, "the surgeon is the big shot-and big shots cop the coin." Too often the only money a physician gets from an operation is an unethical "cut" the surgeon hands him for bringing in a patient (fee-splitting). To protect patients from greedy surgeons, Dr. Bernheim suggests a major operation: "cut out the surgeon--eliminate him entirely from private practice." All surgeons, he believes, should have their offices in hospitals and should receive salaries from hospitals. Patients should choose their hospitals, but leave the choice of their surgeon up to the chief of staff. This system is practiced in the "justly famous" Mayo Clinic. If it were put into general operation, says Dr. Bernheim, surgeons would become more highly specialized and hospitals would weed out inefficient men. Of course, "surgeons won't like it ..• but men ought not to want to make great sums of money ... for cutting into human flesh...." Eventually, thinks Dr. Bernheim, all doctors will band together and practice in clinics, and this streamlined system of medical care will in itself bring greater specialization and raise the quality of service. Once this great step is taken, he believes it will make little difference in a doctor's professional life whether the patient or the government pays the doctor's bill. A PLEA FOR SOCIALIZED MEDICINE By GEORGE W. ASPINWALL (From American Mercur11. Vol. XXXIII, 1934, p. 34.) The practice of medicine is antiquated. The science of medicine has made and is constantly making progress. The general prac­titioner is rapidly disappearing. The know-it-all and do-it-all doctor it1 a person of the past. Efficient medical practice can only be ob­tained through groups of doctors. These groups contain specialists in the various bi:anches of medicine. With proper integration and cooperation in such groups the patient receives the best medical at­tention. It has been shown often enough that the public does not receive proper medical care. The poor receive little attention for minor ail­ments. When the sickness is severe, the poor receive through charitable agencies the best treatment that medical science can supply. The middle class, which constitutes the majority of the population, does not receive adequate medical care. When severe illness occurs, they cannot afford to buy medical attention themselves. Hence they either neglect themselves or they seek charitable or semi­charitable help. The rich pay for medical care and obtain the best that is available. It has been suggested that the cost of medical care be spread throughout the population. By this means the expenditure of large sums of money for a severe illness will not fall upon an individual or a family group during a short period. The income of doctors from the practice of .medicine is rapidly decreasing. It is worse in 1934 than it was in 1933. There are still some doctors whose incomes are from $50,000 to $150,000 yearly, but the earnings of many physicians have shrunk below the subsistence level. The reason for the constant shrinking of the income of doctors i!' that more and more people are receiving medical charity each year. Unless some change is made in the method by which medical service is dispensed, chaos among doctors will occur. Symptoms of this are already in evidence. Singly and in groups, doctors are clamoring for the correction of abuses which have curtailed their income. They desire that doctors be paid for services to the poor, that people who are not entitled to charity should be excluded from clinics, and that the activities of pay clinics should be curtailed or abolished, and public health agencies be compelled to stop practising medicine. But the consensus of expert opinion is that such changes will not really help the doctor or the public. The Committee for the Study of the Cost of Medical Care recom­mended that a drastic change in medical practice be made, but the American Medical Association has stated many times since that it looks with disfavor upon all changes. Last year the delegates to the American Medical Association instructed the trustees to use every effort to stop any movement for a change by the profession itself. Among the delegates there were many doctors whose incomes are quite large. Some of them have been accused of obstructing the trend toward socialized medicine because of the fear that if an alteration occurs, their incomes will be leveled with that of all physicians. That many members of the American Medical Association are not in accord with its policies is seen from the fact that the American College of Surgeons has endorsed some form of health insurance. The agencies that supply medical services are doctors, dentists, nurses, druggists, hospitals, and other factors too numerous to men­tion. They have a large stake in the matter because a change in practice will alter their economic status. The public pays the bill; it therefore must be thoroughly informed about all of its phases. II Health insurance has been suggested by some and state medicine by others. Health insurance is generally a system of medical prac­tice which includes only a part of the population and some of the doctors. It is usually related to unemployment insurance, though plans have been formulated in which employment security is not a feature. State medicine is a system that includes the entire popu­lation and all of the agencies which render medical service. Some of the advantages and disadvantages of each system will now be considered. Health insurance organizations exist in many countries, particu­larly in Europe. They are applicable mainly to the working class with incomes of $1,200 a year or less. The employer, employee and government each contribute one-third of the cost. In some countries the government pays less. However, pressure is always being used by health insurance societies to force the government to shoulder more and more of the financial burdens. This would allow politicians to dictate the policies and the personnel of the societies. Labor organizations have always objected to health insurance because they feel that the worker should receive a return for his labor sufficient to allow him to pay for his medical care. The system, as it now exists, has lowered living standards, since the worker pays part of his salary for health insurance and con­tinues giving, without interruption, throughout his entire life. The employer raises the price of goods so as to offset the outlay for health insurance. By so doing the burden is thrown on the purchas­ing public. Employers will not submit to a reduction of earning for the public benefit. The government must levy taxes in accordance with its needs. When sickness insurance came into being, taxes were raised. Each time the government contributes more money to health insurance, a greater levy is demanded from the public. The worker, therefore, pays for most of the expense of health insurance and is impoverished thereby. In a number of health insurance schemes, the dependents of the worker receive equal benefits, but are not required to make cash payments. In others, the wage earner is compelled to pay for the medical care of those dependent upon him. Under most health insurance systems, the people involved are farm, mill, factory, railroad and shipping workers; also coal and metal miners. It was not the intention to include in these systems the indigent, middle-class or well-to-do. Lately, there has been a tendency to allow those whose incomes and earnings are greater than $1200 to participate. This step would only help reduce the number of cases available for private practice. After health insurance systems have been in operation in a locality for a sufficient length of time, the worker imposes upon the system by going to the insurance doctor at the slightest provocation. If the doctor is careful, many serious illnesses are recognized early, and proper treatment is instituted. However, the worker seeks the help of the insurance doctor for many trivial illnesses, some of which under other systems of medical practice would require and receive no attention. The worker feels that he must get some return for the money he has contributed over a long period of time. Many cases of malingering have been reported. For this reason the doctor is com­pelled to assume the function of detective, so that the interest of the company may be protected. Functional nervous ailments have in­creased tremendously. It is conceded that they are real, having their origin in the fact that the ordinary worker is a part of the machine and thus loses his individuality. By becoming ill and receiving medical attention, which is a personal matter, his egotism is stimu­lated and satisfied. The whole thing springs from the fact that human beings resent the boredom, noise and confinement of constant work and unconsciously, perhaps, use sickness as a means of escape. III It should be of interest to know that the domestic servant in England has made exceptionally heavy demands for sickness insur­ance benefits. When health insurance was being put into effect, it was found that these people were unusually healthy and seldom re­quired medical attention. The increase in the number of cases of illness in this class has been attributed to health insurance. This situation has been found to have occurred among the workers in all of the countries in which health insurance has been established. The morbidity figures have increased constantly, and these have no relation to the economic con­dition of the country. in which they live. The death rate, however, has not increased. Doctors are considered by the health insurance organizations as employees. Since they are not productive in the monetary sense, the cost of their services is necessarily put on the expense side of the ledger. The administrative and managing part of the business is deemed to be of greater importance than medical services. At first, these organizations sold the idea of health insurance by telling the public and the employer about the efficient medical services they could provide. Later, the expensive buildings, equipment and cash payments to the workers, were emphasized and the medical care as­sumed secondary importance. When health insurance was established in some of the European countries, the remuneration received by the doctor was much greater than under the old system of practice. The doctors were very well satisfied, but not many of them could get jobs. Nowadays, the re­turn which the insurance doctor receives, is exceedingly small. At first, insurance doctors were paid for each visit. This was changed so that the doctor is paid for each case. The excuse given by the insurance societies was that, under the former system too much bookkeeping was involved. In England the doctors are paid by the Ministry of Health. The average total income of the insurance doctor in England was, in the beginning, $2,250 a year. In 1931, because of the necessity of national economy, the doctors accepted a reduction of 10 per cent. After deducting income tax, office maintenance, transportation, etc., it has been found that the net income of the British doctor under the panel system is less than $1,000 a year. In some countries, insurance societies restrict the doctor in his treatment. This applies particularly to the prescribing of advertised and expensive drugs and apparatus, whether or not they have merit. No self-respecting, scientific doctor will work for any length of time under these restrictions. Some of the insurance companies, in a number of their medical institutions, give massage, light, electrical and bath treatments to insure groups and others, for which a fee is charged. This money goes into the treasury of the insurance society, and none of it reaches the medical workers. Many employees become dissatisfied with the medical service given to them by the insurance doctors. Usually they employ quacks. In Germany, according to one authority, there are nearly 13,000 quacks. They have an organization and publish a great many journals with disguised names. These journals are distributed to the public. The reading matter contained therein is such as to in­ftuence the people to patronize irregular practitioners. In France, the insurance societies pay a certain basic amount for medical care. The doctor may charge whatever fee he thinks neces­sary above that figure. The employee must pay the difference. The French doctor is assured at all times of the basic contribution of the insurance companies. Doctors in France, therefore, are much better off than those in most other countries. General satisfaction with the system has been expressed by the Royal Commission and the British Medical Association in 1926. In France and England the control of health insurance is in the hands of medical bodies. This accounts in a great measure for its effi­ciency. The control of health insurance organizations in most other countries is in the state of flux. When the control is in the hands of medical men, the other factions make efforts to wrest the man­agement from them and vice versa. In 1928, the General Council of the International Medical Association resolved that "The Association fully approves of the principle of sickness insurance for the poorer classes of the community. This principle represents a great social advance and a powerful factor in the prosperity and welfare of nations." In health insurance no provision is usually made for dental care or the prevention of disease. The burden for the latter is borne by public health agencies. It is obvious the general public, through taxation, pays more than its just share for the care of a favored group in the population. Schemes for medical service have been advocated for groups earn­ing from $1,200 to $3,000 yearly. Unpredictable severe illnesses may occur in families whose earnings are above this figure. Many in­stances are on record showing that the care for some of these ill­nesses consumes 100 per cent or more of the total income, if all of the agencies necessary for the care of the sick person or persons are adequately paid. It usually happens, however, that the doctor and other medical aids are compelled to accept less than their just compensation. Even charitable agencies are finally called in to subsidize the family in its extremity. It becomes necessary, there­fore, to seek methods by which the entire population may obtain medical care commensurate with its needs. State medicine (socialized or public) would supply all of the de­sirable elements toward the solution of this problem. The .salient features of the program of the Medical League for Socialized Medi­cine is as follows: Adequate medical care for the sick and injured is a social function, right and duty, not a private or public charity. State medicine is a socialized system of medical care in health, illness and injury, free of fees, under the auspices of the State and financed by taxa­tion. It should be operated and regulated by organized medical and allied professions, the medical and dental colleges, and the officials of public health agencies. It should include all dental, pharmaceu­tical, nursing and allied services. IV All buildings, supplies and apparatus are to be publicly owned. The hospitals and clinics should be orga.nized as medical centers properly coordinated and geographically distributed. Calls for at­tendants upon the sick at home are to be received at these centers, such calls to be assigned to physicians designated to cover specific local territories. All equipment, supplies, laboratory and other facilities of medical, surgical, dental, pharmaceutical, nursing or other nature are to be furnished free. The education of the medical, dental, pharmaceutical, nursing and allied personnel is to be supplied free by the state. All duly licensed or registered dentists, pharmacists and nurses are to be legally entitled to practice under this system on a full time basis, subject to established rules and regulations of admission and practice. Their rights and privileges are to be safeguarded, and they should have representation and a voice in the operation of the system. The compensation should be adequate and graded according to time of graduation, length of service, rank and the type of work. Salary increases and promotions to higher positions are to be based upon similar considerations and automatically enforced. Pensions and sickness, old age and other disability insurance are to be in­cluded. The hours of work should be assigned, regulated and sched­uled, so that provisions be made for competent medical care for the sick and injured at all times. Adequate time and opportunity for all professional workers should be allotted for rest, recreation, vaca­tions and post-graduate study with pay. Group methods of practice are to be employed wherever possible and special provisions made for rural and other territories inacces­sible to regularly organized medical centers. Private practice is per­missible under the same conditions and regulations as in public edu­cation. It is unlikely that this program, if adopted, will be put into effect in its entirety. Changes of this kind can occur only gradually; otherwise failure in its establishment may be safely predicted. The history of public education is a case in point. Its beginning was small, yet gradually it has expanded to the position it now holds and its cost is far beyond the dreams of those who originally pro­posed it. It should be known that in this country, partial state medicine already exists. In 1931, 66 per cent of all hospital beds in the United States were under government control. Fifty per cent of all ward cases in New York City are now subsidized by the municipality and 40 per cent of the ambulatory cases are treated in city hospitals. State medicine is not a system of medical education; it is a medical cooperative service for the benefit of the public, and all those desirous of working in the medical field should come thoroughly pre­pared to render efficient service. Medical, dental and pharmaceutical schools should cooperate with the system so that the number of grad­uates can be curtailed or augmented as required. It will be neces­sary for these professional schools to alter their curricula from time to time so that the graduates will fit into new and expanding de­partments. It may be confidently expected that disease prevention, mental hygiene and psychiatry will derive a great impetus from such an organization. Under state medicine, industrial accidents will automatically be divorced from employment insurance. This will result in substantial saving both to the employer and the state. The other benefits of the system, if it is efficiently conducted, cannot be estimated. By proper measures the morbidity and mortality in infants' and infectious diseases will certainly be reduced. The same applies to the hazards of maternity. The prevention and treatment of chronic diseases is a field that has hardly been scratched and considerable progress here may be expected when conducted under proper direction and management. The saving to the state and citizens may in the end be so great as to justify the system. The cost of state medicine will not be as great as the present system. In 1929 the people of the United States paid for all kinds of medical service nearly three and three-quarter billion dollars. This included fees to doctors, dentists and nurses; hospital care, drugs, irregular practitioners, faith healers and patent medicines. The amount paid for irregular practitioners, faith healers and patent medicines alone was approximately $500,000,000. Because many of the services and equipment overlapped, a great deal more than neces­sary was expended. It has been estimated that every man, woman and child on the average paid for all kinds of medical services nearly $30 a year. A liberal estimate as to the legitimate amount that should have been paid may be placed at $25 a year. If every person in the United States on the average were to pay this amount in addition to the regular taxes, it is felt that it would be sufficient to defray the expenses incident to state medicine. No provision is made, however, in this figure for the purchase of existing hospitals, equipment and the erection of new buildings. The Endicott-Johnson Company, at its plant in New York State, provides 15,000 workers and their families with a well-rounded medical service including medicine, dentistry, nursing, hospitalization and drugs. In 1928 the cost was $25 per capita. Out of the total amount expended for medical services by the people of the United States in 1929, doctors received on an average of $9,000 a year each. About 40 per cent of this was allotted to over­head. With the inauguration of state medicine, this overhead will be eliminated, for doctors will not need private offices. All of their work would be done more efficiently in the medical centers of the system. It is felt in some quarters, therefore, that physicians work­ing under the new system would receive on the average of $7,000 annually net. v In medical practice as it is constituted today, doctors use both their professional and business talents for the purpose of making a;. much money as possible. It is a sad commentary on the present system that those who are rendering medical service should be com­pelled to exact fees, either large or small, from those who through no fault of their own are stricken with illness. Many men in medicine have capitalized this to such an extent that they have become enriched. The talents of men in medicine under the proposed system will not be used for the purpose of making more than a comfortable living. The additional benefits which they will derive, however, will be the respect of the community, enhanced professional standing and the pleasure and satisfaction of rendering services to the suffering. Except for those desirous of paying the doctor directly, free choice of doctor will be lost. This, however, will not be a novelty. In accepting medical charity, over 70 per cent of the sick people have lost their privilege of selecting a doctor for the treatment of their ills. The physician has also relinquished, in part at least, his right of treating patients of his own choosing. In the wards and clinics of hospitals that right has been abrogated. It has been said that under state medicine the urge for research and accomplishment in medical sciences will be stultified. Most of the discoveries and advancement in medicine have been made by men working on salaries in the laboratories or by clinicians employed on a full-time basis. It is likely that when the necessity of struggle for a livelihood has been eliminated, the urge for creative work will be lessened. But there is another side to the question. Under state medicine, doctors will not become careless because their incomes and positions are guaranteed. '!'he practice of medicine is no longer a one-man job. Except in self-limiting and minor ail­ments, laboratory work and consultations are necessary for the proper management of a case. In this way, a certain amount of supervisory control is exercised even today. Under state medicine, the doctor could not afford to become careless, for his advancement in the system would thereby be put into jeopardy. Politics will no doubt play a considerable role in the organization of state medicine. It is impossible to avoid it because of the many elements that serve to initiate and perpetuate the system. We are dependent upon legislators to vote for the proposal before it can have a beginning. It is common knowledge that our law-makers will not encourage the enactment of a project for which large sums of money will be expended unless they can control the disbursements. But, when the force of public opinion is sufficiently great, these gen­tlemen will do its bidding irrespective of their personal interests. Politics exerts its influence in state education, but neither the public nor the teachers are desirous of a return of private education for the majority of the people. SOCIALIZATION OF MEDICINE By THE MEDICAL LEAGUE FOR SOCIALIZED MEDICINE* PREFACE The Medical profession faces a serious situation-a menace to the very existence of the doctor. The menace consists in the disorganized and disappearing practice of the doctors. This is partly caused, partly aggravated, by the commercial competition of private clinics and hospitals, dispensaries, sanitaria, medical centers, foundations, insurance and industrial medical departments, lodge and contract practice, state and municipal public health departments, clinics and agencies, and state-favored private medical services and organiza­tions, not to mention all the various cults, commercial quackery, counter-prescribing, and self-treatment. The doctor cannot solve his problem by evading the issue or by romancing about it. He must face the realities of economic and medical life. The prevailing general economic conditions of depres­sion have still more accentuated the sad state of the doctor. He must seek out the basic causes of his plight, and he must be pre­pared to apply fundamental, and, if need be, radical remedies. He •This organization has been reorganized and Is now known as the American League for Public Medicine, 1457 Union Street, Brooklyn, N.Y. cannot do this alone, as an individual. He must do this together with his fellows, by organization for this purpose. The day of so-called "rugged individualism" is gone forever and has left only "ragged" individuals. Private competitive practice is an anachronism and a failure. It is economically unsound. It is expensive or inadequate or both for those who do obtain medical care. It fails to provide any medical care for many. It fails to provide a proper and secure living for most of the doctors who render this medical care. Private individual practice is a failure because it is essentially unscientific and un­workable in practice. The progress, achievements, technique, technical equipment, specialization and organization in modern scien­tific medicine, make the individual practice of medicine out of date. Cooperative scientific work and groups are the order of the day. Private individual practice has moved out of the home into the in­stitution, just as individual industry has moved out of the home into the factory. Hospitals, clinics, centers, etc., are here to stay, and they will rule and ruin the medical profession, unless they are ruled by the medical profession. If the doctor will not realize all this immediately and act accord­iugly he will invite total economic disaster; or else, he will succumb to some form of contract practice or some vicious form of health in­surance. The doctors must have a true understanding of the real situation that is before them, a realization of the actual causes and the logical cure of their serious condition, and a cooperative organiza­tion to advance the best interests of the profession and the public. With these objectives in view, the Medical League for Socialized Medicine has been formed, and it urges upon the medical profession this statement of its Principles and Program for most serious con­sideration and adoption. PRINCIPLES The health of the people is the people's concern. Public health is a public matter. The physical well-being of the individual or the people is as important as the material, mental and moral well-being. Health is no less important than education, property, protection, etc. Public health does not mean merely the narrow field of the ordinary public health services or agencies concerned with sanitary and pre­ventive medicine, or with disease of an epidemic or an occupational character. It involves the broader conception which includes the prevention, care and cure of all illness and injury of the individual. Individual illness not only most often has social-economic primary or contributing causes, but also just as often has critical social~ economic consequences, especially to the individual. Disease usually spells disaster to the individual and dependents, and economic loss and disturbance to society. The people's health, including the care and cure of disease and injury, is, therefore, fundamentally a social or state interest and obligation. It is essentially a state function and it should no longer be left to the economic and medical exigencies and uncertainties of present private individual or institutional practice. Adequate health care, like all other social functions, must have a proper system of medical practice to properly fulfill and realize this social function. Health must have proper and full legal and governmental sanction and subsidy, side by side with education, or policing, or fire-fighting, or courts, or any other functions of the government of city, state and nation. Social justice, social responsibility and social need-not charity-must be the underlying principles of a proper system of medical care and practice. The interest of the patient and the doctor, of the public and the profession, must be adjusted so as to become identical, by removing all possibility of difference or conflict. This can be done only by removing from the sphere of relationship between the doctor and the patient all influence of any immediate economic consideration or obstacle, all motives of a financial or personal nature. Private in­dividual or institutional practice, based on the fee-payment system, does not permit true harmony of interest between the profession and the people. Private competitive practice, whether by the individual doctor or mdical institution, often under the cloak of charity, and just as often animated by commercial motives, yielding either profits or losses, results in expensive and inadequate physical care of the people, while the life and work of the physician is insecure, often poorly paid, just as often not paid at all, and generally demoralizing and degrading. Neither the people nor the profession get a square deal. Insecurity is the lot of both. The physical care of the people during illness as well as health must be assured and adequate. The doctors must give this adequate medical care to the people, all the people, all the time. But the physician and public are mutually interdependent. Health is purchasable and must be paid for by the people. And the principle of security must apply to the physicians as well as the public. The work and the living of the doctors must be likewise adequate and assured. The doctors must be secured of an adequate economic and professional existence. The people must pay the doctor for his medical care, and the doctor must pay for his living by giving this medical care. Health security for the people; economic security for the physician! There is only one real remedy for the social disease of inadequate and costly care of the health and illness of the people. Likewise, there is only one real remedy for the complicating social disease of inadequate pay and insecure work of the medical people whose func­tion is to render this medical care. That one and only remedy is Socialized Medicine. Socialized Medicine implies that the people have a right to adequate medical care guaranteed by society through the state or the govern­ment, and that the doctors have a right to work and be paid for their work adequately and likewise guaranteed by society through the state or government. Socialized Medicine implies a system of medical care and practice, sponsored and financed by the state, responsible to the state, and organized, operated and regulated dem­ocratically by the medical and allied professions themselves. The socialization of the practice of medicine is socially just, eco­nomically sound, scientifically correct, and therefore desirable and workable. Such a system of Socialized Medicine can be achieved­must be achieved. It is the only really practical and scientific solu­tion for the Doctor's Dilemma. To achieve this ideal solution, the Medical League for Socialized Medicine submits the following Plat­form or Program of measures and means to be developed into law, and to serve as a basis upon which to establish an adequate system of Socialized Medicine, with adequate care of the people by the doctors and adequate care of the doctors by the people: PROGRAM 1. Adequate medical care of the sick and injured as a social func­tion, right and duty, and not as a private or public charity. Curative as well as preventive meanit, measures, and agencies to be included. 2. A socialized system of medical care in health, illness and injury, free of fees. (a) Under the auspices and with the subsidy of the state. (b) Financed by taxation, similar to the public educational system or other governmental functions. ( c) Operated and regulated by the organized medical and allied professions, the medical and dental colleges and the officials of exist­ing public health agencies. (d) This system to include all dental, pharmaceutical, nursing and allied services and personnel. 3. All hospitals, clinics, laboratories, pharmacies, etc., to be pub­licly owned and operated institutions, accessible to the sick free of charge. The hospitals and clinics to be the medical centers for ward and ambulatory cases, and to be properly organized, coordinated and geographically distributed. House sick calls to be received at these centers and to be assigned to local or neighborhood physicians des­ignated to cover specific local territories. 4. All equipment, supplies, laboratory and other facilities of a medical, surgical, dental, pharmaceutical, nursing or other nature, to be furnished free by the state. 5. All medical, dental, pharmaceutical, nursing and allied education to be furnished free by the state. 6. All duly licensed or registered physicians, dentists, druggists, nurses, etc., to be legally entitled to practice under the system as full time practitioners or workers. (a) Subject to established rules and regulations of admission and practice. (b) Proper safeguards of their rights and privileges under the system and the law. (c) With representation and a voice in the operation of the sys­tem. 7. Compensation to be adequate and on a salaried basis. (a) Graded according to time of graduation, length of service in the system, rank held, and type of work. (b) Salary increases and promotion to higher ranks to be based on similar considerations and to be automatically enforced. (c) Pensions, sickness, old age and other disability and social insurance to be included and applied. 8. Hours of work to be assigned and regulated and scheduled so as to provide : (a) Adequate medical care for the sick and injured at all times. (b) Adequate time and opportunity for the physicians and allied workers for rest, recreation, vacations, and further professional study -with pay. 9. Organized cooperative groups and group methods to be employed under the system wherever possible. Special provisions to be made for rural and other territories inaccessible to regularly organized medical centers. 10. Individual private medical practice permissible under the same conditions and regulations as in private education, plus existing licenses and requirements by the state. PLATFORM OR STATEMENT OF PRINCIPLES AND PROGRAM By THE MEDICAL LEAGUE FOR SOCIALIZED MEDICINE* PREFACE In advocating the socialization of medicine, no claim is made that socialized medicine is a Utopia without any imperfections. No human *Now the American Leal'Ue for Public Medicine, 1467 Union Street, Broklyn, N.Y. being is perfect, no government is perfect. Why expect an absolutely perfect system for the medical profession? What matters most of all is that socialization of medicine is the best possible system as com­pared with the present system of medical practice. More stress has been given by those who oppose the socialization of medicine to the objections to the system and little, if any, to its bene­fits. An attempt is made here to discuss briefly these objections. 1. What is the difference between socialized medicine and st.ate medicine1 Socialized medicine implies a system of free medical care and prac­tice sponsored and financed by the state, responsible to the state, and organized, operated and regulated democratically by the medical and allied professions. State medicine implies the very same thing as above, except that the system of medical care and practice would be organized, controlled and regulated by the state for the medical and allied professions. (See platform of the Medical League for Socialized Medicine. See also No .. 23 of this questionnaire--Objections on "Politics.") 2. Is insurance mediC'ine as practiced in Germany socialized med­iC'ine? Absolutely not. It is a large scale contract practice under the control of the state and complicated by private practice. It can be in some way compared to the present workings of our Workmen's Compensation Law. Insurance medicine should be opposed by all doctors, because: (1) Profit to insurance companies is an essential factor. (2) Politics will surely enter. Insurance companies maintain ex­pensive lobbies. (3) Insurance companies will control the medical policies. (4) Competition by doctors for jobs with insurance companies will be a certainty. (5) The doctor will be insecure in his position and earnings. ( 6) Medical insurance is not applicable to all patients, but only to those who are able to pay the costs of insurance. (7) Experience with the present compensation law yields poor re­sults to both patient and doctor. Socialization of medicine: (1) removes the middleman (insurance company), eliminating his profit; (2) is applicable to all the people; (3) competition for jobs will not be necessary; (4) financial security and tenure of office will be assured. A warning and prophecy: Unless the doctors adopt some such plan as socialized medicine, some form of insurance medicine will be thrust upon them. Insurance companies are ever alert where profit is to be had. 3. ls tM W orlcmen's Compensation Law similar to socialized medicine? No. It is a form of insurance medicine under the supervision of the state. It is a private contract practice permitting a profit-making organization (insurance company) to come between the patient and the doctor. All its abuses have arisen because of this and because of the "business" the doctors have made of it. All compensation C'llses under socialized medicine would be handled the same as any other medical or surgical cases. 4. Can medicine be socialized in an unsocialized state? (1) The state we live in is not an "unsocialized state." We would have to close shop in many things and go back to the old never-to­return days, if this were true. We live in an already partially social­ized state. Public education, fire departments, water departments, health departments, sanitary departments, police, parks, public libraries, recreation centers, public hospitals, bridges, municipal fer­ries, concerts, and many other activities and institutions too numer­ous to mention, in this and other cities, states and countries, show the extensive trend toward socialization and already in operation even under the present system. (2) Even medicine has long been under control or regulation by the government, although not actually socialized. Medical practice acts, examinations and licenses, health department control and regu­lation, and narcotic and alcoholic control, are examples of state con­trol of medicine under the present system. (3) Lest we forget, partial state medicine does exist under our so-called capitalistic state. "In 1931, 66 per cent (66%) of all the hospital beds in the United States are under government control. More than one-half of the general hospital care is provided by cities and counties through local hospitals." (Wilbur report.) More than 50 per cent of all ward cases in our voluntary hospitals in Greater New York are now subsidized by the Government. Approximately 40 per cent of all ambulatory cases are handled through the city hospitals. 5. Healtk is a, necessity. But why not socialize otker necessities, such as food, clotking and kousing? Wky pick on medicine? (1) As doctors, we must necessarily be interested in the questions of food, clothing, shelter, etc., since the health of the individual is involved. Much illness can be averted if the people were assured of these necessities. However, as doctors, we are naturally primarily interested in correcting the present inadequate system of medical practice and health care, and, although the other necessities of life are very important, the question of the socialization of these other neces­sities must be left to the people as a whole to determine for them­selves. (2) From a practical viewpoint, the industrialists would oppose the socialization of food, clothing, etc., since their interests are directly involved. However, they would not oppose the socialization of medi­cine since, under such a system, they would be relieved of the burden of charity which many of the rich bear today, placing it upon society as a whole, where it really belongs. 6. Can organized medicine prevent tke socialization of medicine? Organized medicine, although it recognizes the need for readjust­ments in the practice of medicine, has in no way proposed a concrete plan that would be acceptable. In the meantime, while it has adopted a laissez-faire attitude, in hoping for better times or for some miracle to happen, other forces (social, economic and political) are at work. Who would believe that industry, guided by the strongest element in the country (capital), would have to abandon "rugged individual­ism" and be forced to accept government control? If industry could not prevent the Government from entering into its business, will it be possible for the A.M.A. to stop the socialization of medicine when that becomes necessary? Can a hundred thousand doctors, more or less organized, stand in the way of the needs and demands of one hundred and twenty-five million people? "There is one lesson that can be derived :from history. It is this: That the physician's position in society is never determined by the physician himself, but by the society he is serving. We can oppose the development, we can retard it, but we will never be able to stop it." (Prof. H. E. Sigerist, Professor of Medical History, Johns Hopkins University.) It would seem the better statesmanship to right-about face, in view of the new understanding, and ride the crest of the tidal wave rather than foolishly fight it. Then, when the Government gets around to the socialization of medicine, the doctors will be prepared with a suit­able plan. Without such a plan, and showing opposition to the socialization of medicine, the doctors will get something which they really do not want. (See also answer to question No. 4,) 7. Will the present policy of organized medicine solve tke problem of adequate care of tke patient witk proper financial return to tke doctor? Organized medicine has no definite constructive plan. Its policy is (1) Laissez-faire. It hopes that when and if times improve, the peo­ple will be able to purchase medical care. (2) It intends to resort to palliatives to patch up a system which, it admits, has not given adequate care to all the people, nor ample remuneration to all the doctors, and thus to correct the evils and abuses that are all but annihilating the profession. It is not made clear just how they can stop advertising and self­medication involving the million dollar drug companies; the increased clinic attendance with public opinion to contend with; corporate and lodge practice that has existed for years; cultists of all kinds who thrive in spite of all efforts to eradicate them; fee-splitting and other commercial and degrading practices that are condemned, yet exist now more than ever. The fact remains that none of these abuses were eliminated, and all are ever-increasing. Merely protesting cannot produce results or solve the problem. Socialized medicine demands that the responsibility for the health of the people be assumed by the state and not by the individual doctor. Socialization of medicine would eliminate the abuses of med­ical practice. The need for self-medication would be eliminated. Corporate, contract, and cultist practice would be eliminated. Fee­splitting and other such practices would have no place under this system. Clinics would continue, but all work would be paid for as a matter of course. (See Platform, section on Principles, of the Medical League for Socialized Medicine.) 8. Under socialization of medicine would free choice of physician be lost? At best, this free choice of physician is largely a myth and very limited in scope: (1) Limited funds limit the choice. Only the rich can choose any doctor they please. The vast majority of people who constitute the great bulk of patients, have no real choice, but are guided by what they can afford to pay. They may know who the best doctors are, but cannot choose them. (2) Given a patient of ample means, who can deny that he can get excellent diagnosis and treatment at, for example, the Mayo Clinic, even though he does not choose there his individual doctor? (3) All ward cases in hospitals have no free choice of doctor. Yet it is admitted by all attending that these cases receive superior medical service from the physicians. The money motive is absent, and anything and any consultation can be ordered and secured that may be of value in diagnosis and treatment. This is not true of private cases in the same hospitals on account of financial con­siderations. ( 4) Public institutions, without free choice, offer excellent. service and, all things considered, have excellent records. (5) If a physician is not associated with a certain hospital, then, if hospitalization is required, the patient is unable to continue the doctor's services, despite his choice of physician. Most hospitals are "closed." (6) Most "open" hospitals permitting "free choice," are generally considered inferior institutions by both laymen and profession. (7) Free choice as it exists today is unscientific, unreliable and undesirable. A neighbor, relative, friend or busybody, a fine office (location, furniture, nurse, etc.) expensive automobile, clothes, enter­tainment and personality, etc., all go into the determination of "choice," of how learned ( ?) and competent ( ?) the doctor is. Often, then, a wrong choice of physician is worse than no choice at all. The layman is in no position to judge the physician. The more successful doctors are not necessarily the more competent ones. 9. Will not personal relationship between patient and doctor be lost under socialized medicine? This "personal relationship" today is also largely a myth, and all the considerations pertaining to the question of "free choice" apply with equal force to the question of "personal relationship." (See No. 8 above.) "A confused and illogical relationship exists today between the medical profession and those whom it serves." (Dr. Richard Cabot, Professor of Medicine and Social Ethics, Harvard University.) (1) The doctor cannot claim that he retains his families under his care continuously. Patients travel today from doctor to doctor, from specialist to specialist, and from clinic to clinic. This is often because of lack of faith or lack of funds. Often there is actual mistrust for economic, if not even scientific reasons. Surely personal relation­ship is not, cannot be, retained under such conditions. (2) The see-it-all, know-it-all, do-it-all oldtime family doctor is rapidly disappearing, despite all the lamentations for his return by organized medicine. All the king's horses and all the king's men will not bring him back again. You can go forward, and even mJl,rk time, but it is a herculean task that organized medicine is attempting, namely, to go backwards. The specialist, the laboratory, the hospital, are here to stay. There must have been a reason for this develop­ment. With the advances in medicine, no one man can know every­thing-a master of all is a master of none. With the advent of specialization and laboratory investigation, how much personal rela­tionship can exist between the patient and the laboratory, the clinic or the hospital? ( 3) A new type of personal relationship is bound to arise under the socialization of medicine due to the absence of the economic motive and the skepticism and mistrust resulting therefrom. 10. Will not responsibility for tke patient's welfare be divided under sbcialization? (1) True ideal total individual responsibility can be obtained only when a physician is absolutely self-sufficient. He would have to be a general practitioner, surgeon and all other specialists, rolled into one, and all first-class. He would have to have all the equipment and laboratory facilities in every field of medicine, and be expert in their usage. (See No. 9 (2) dealing with "Personal Relationship," above.) (2) Under the present system, especially in large cities, no doctor can treat any disease, except the minor ones, without assistance from others, and consequently, sharing the responsibility with them. Upon referring a case to a surgeon, specialist, consultant, or laboratory or hospital the responsibility should be divided since the work is divided. Yet, often today, the general practitioner is unjustly held responsible for a case long after it has left his care and gone into the hands of the surgeon, the specialist, or even the hospital. 11. Would socialized medicine 1mean mass treatment? (1) What is "mass treatment?" Does it mean treating a dozen, or fifty, or a large number of patients at one time? That method can be used only with the most general and simple procedures, such as vaccinations, immunizations, etc. All other forms of examination and treatment must necessarily be individual under any system of prac­tice. Standardization and systematization of examination and treat­ment is scientific and does not necessarily mean mass treatment. (2) In clinics and wards of hospitals, numbers of patients are treated, even at present, and yet each case is examined and treated individually and as required. 12. Would not SocWlized Medicine reduce the profession to the status of a trade? (1) If by a "trade" is meant a business, then medicine, by its commercialization, by its economic and business considerations, has long been reduced to such a status. (2) If by a "trade" is meant a form or type of skilled work, then the profession need not deny or fear such a status, but should rather acknowledge it. We are skilled workers; but we are not a "holier­than-thou" class. (3) The public-employed school teachers have not suffered as a profession nor have they been reduced to a trade, because of the socialization of their profession. Can anyone say that Dr. Wm. H. Park is not practicing a profession, but is pursuing a trade in his great work as a public employee in the service of the Health De­partment of New York City? 13. Would not the incentive and ambition of the doctor be lost under socialization? (1) What ambition? Is it the incentive and ambition (a) to make money or (b) is it the scientific ambition, that will be checked? The answer is very important. If it is the former ambition, then it is true that financial gain will be limited. A secured livelihood, and not wealth, will be made under socialized medicine. A business career, and not the medical profession might be the proper place for those having ambition to make money. The security and adequacy of a livelihood for the mass of the doctors is of far greater moment than the inordinate incomes of a few doctors. Even today, under the present system of private practice, how many are guaranteed the security of a livelihood, much less the accumulation of wealth? (2) On the other hand, scientific ambition will not be checked under Socialized Medicine. Socialization of Medicine will stimulate ambition. "The greatest scientific advancements in medicine are not now coming from the field of commercial struggle for existence occu­pied by the medical profession. They are coming from the men who, by public or private means, have been removed from its blighting in­fluence. The financial reward has not been the object which has stimulated the great medical discoveries. Now it is well recognized that the doctor who is engaged in the competitive struggle for a livelihood is the least apt to contribute to the progress of medicine, or of science. Surgery is the last exception but it is rapidly becom­ing commercialized, and soon its best progress will depend upon the financially independent workers. The whole history of medicine, with its splendid list of martyrs, is a glorious refutation of the sophistry that competition for profit is important to human progress. The competitive system which surrounds and harasses medical ad­vancement, hindered it from the beginning and retards it still." (Dr. James Peter Warbasse.) 14. When the position is guaranteed will not the doctor be slipshod and lack interest in his work? On the contrary! Under the present individual office care of patients, he is apt to be slipshod. No one supervises or controls his ability, methods used, equipment necessary or the keeping of the records. Under Socialized Medicine, there would be supervision and control, and rightly so. To keep his position, the doctor would be compelled (1) to be up-to-date in knowledge, (2) perform only such duties as he is capable of doing, (3) use only accepted scientific methods, and (4) keep proper records. Our best workers in scientific medicine are generally salaried full-time men who are not slipshod and whose interest and ambition. do not lag. "Aside from the alleviation of suffering, the strongest impulse which moves the physician is the professional motive of winning the esteem of his fellows . • . the medical profession has, from time out of mind, disclaimed the acquisitive motive." (Walton H. Hamilton­Final Report of the Committee on the Costs of Medical Care.) 15. Has not medicine made scientific advances even under the pres­ent system? It is remarkable that so much has really been accomplished. How much more would have been accomplished if all the efforts were co­operative and coordinated? But really, how much of this progress was accomplished by the practicing physicians, and how much by the full-time salaried workers? (See Questions No. 13 and 14, In­centive, Ambition and Interest.) 16. Would not the independence of the doctor be lost under social­ized medicine? The doctor today has neither economic independence, scientific in­dependence, nor personal independence. Genuine independence can only be secured when the doctor is independent economically. What percentage of doctors can claim economic security? Scientific in­dependence is absent at present since the doctor has to compromise when treating his patients because of their inability to pay the cost of the best attention, diagnosis and treatment he can give them. J:t,rom a financial standpoint, the doctor is at the beck and call of all at all times; he is dependent upon the patient, the hospital and its politics, the prejudices and ignorance of the people he serves, with no time that he can call his own. 17. Would an initial salary of $9,000 induce the proper men to study medicine? (1) When you consider that the cost of medical education under the present system amount to $15,000 to $20,000 it seems absurd that the net annual income of one-third of all private practitioners should be about $2,500. (Wilbur Report.) (2) Under socialization, the cost of medical education is borne by the state, and not necessarily by the individual. Then a $3,000 net salary is not such an anomaly. It should be realized that under Socialized Medicine there will be a minimum and a maximum salary. Besides, medicine will then attract only the men who are really interested in medicine and not in commerce. (See Questions No. 18 and 19.) 18. How can a doctor be satisfied with a $9,000 net salary, when a policeman without any real training receives like compensation? This objection seems valid. It is no secret, however, that financially education does not pay. Can anyone explain why even the best pugilist should earn more money than the soldier who fights on the firing line, or than the President of the U. S.? Does it not seem strange that an ignorant real estate builder should earn more money than a President of a university? Again, does it not seem strange that a motion picture actress should earn more money than the combined earnings of one hundred of the best physicians? If "big" money is what the doctors are thinking of, the sooner they will leave the profession to take up pugilism or some business or racket, the better for them. It should be realized that under socialized medicine there will be a minimum and a maximum salary. Socialized Medicine does not propose to attempt to rectify an in­justice and inequality that is centuries old. Security and adequacy of income and livelihood are the prime considerations. 19. How much money would a doctor receive as compensation under socialization? (1) He will receive an adequate secured salary that will auto­matically increase, depending upon the length of service, type of service, and position held. The amount will depend much upon the doctors themselves. If they are organized and demand proper terms, they will get just what is legitimately due them. Remember, all salaries would be net. (2) The past and present earnings of the doctors will no doubt be taken into consideration. "The average gross income of all physicians (from the lowest to the highest income) in 1929 was $9,000." (Wilbur Report). That amount does not sound so bad, and, if offered, would be acceptable to the average physician. One need not be fooled, however, since "approximately 40 per cent of this gross income goes for professional expenses, transportation and other items." (Wilbur Report.) The results of the investigation show further that in the very best year (1929) "one-third of all private practitioners had a net income of less than $2,500. For every physician with a professional income of more than $10,000, there were two who received less than $2,500. The contrast is especially great between general practitioners and specialists. In 1929, the seventy thousand general practitioners, as a group, received less income than the 30,000 complete specialists. The average net income of the former group was under $4,000, while that of the latter group was over $10,000." (Wilbur Report.) This gives us an idea of the earnings of the physicians in the very best year (1929.) What the earnings were before 1929, and what they are later, is something else to think about. "The average reduction for physicians in all areas (from 1929 to 1930) was 17 per cent. In 1931 and in 1932 still further declines were suffered.'' (Wilbur Report.) (3) In considering the physician's earnings, we must make up our minds to accept the following: (a) The boom days are over. To think of the present and the future, and not of the past, is the better part of wisdom. (b) The present earnings are dangerously low. The average doctor will surely receive more than he is earning now, under Socialized Medicine. (c) No one can guarantee the future under the present system of medical practice. No one should be fool enough to believe that "prosperity is around the corner.'' 20. Would every doctor be placed under socialized medicine? (1) We deny overproduction of physicians. We believe that there is instead a poor distribution of doctors today. At present, there is one doctor for every 621 people in New York State; one doctor to 571 in California; one to 1431 in South Carolina, and one to 860 in the United States. It is only under the present fee-for-service system with poor distribution, that so-called "overproduction" persists. This ii; because: (a) Preventive medicine is hardly practiced. People are unwilling to pay the doctor for periodic health examinations when in good health. (b) Clinics and hospital wards are competing with the doctors. Over two million in Greater New York now attend these clinics. (c) Health departments are placed in a position of competition with the doctors. Well-baby clinics, venereal clinics, tuberculosis clinics, vaccinations, immunizations, school examinations, etc., deprive the doctors of legitimate income. (d) Corporations are competing with the doctor. All large busi­ness and industrial enterprises now take care of the health of the employees. (e) Self~medication through counter-prescribing and through vast advertising campaigns (via radio, newspaper, etc.) is a form of com­petition with the doctors. (f) Cults and all sorts of quackery are effective competition. (g) A large percentage of people receive no medical care at all, according to the reports of the Society for Improving the Condition of the Poor and of the Committee on the Cost of Medical Care. When all these encroachments are taken into consideration, is it any wonder that there is very little work left for the doctor. That is why we have an abundance of doctors with no patients. And what work there is for the doctor is usually underpaid or unpaid. (2) On the other hand, under Socialized Medicine, even with one doctor to every 500 people, there will be plenty of work for the doc­tor. Because: (a) Charity clinics and wards, as we know them, will become socialized clinics and wards, where the doctors' work will be paid for as a matter of course. (b) There will be no need for corporate or contract practice. (c) Self-medication and cults will be automatically eliminated. Why spend money on patent medicines, etc., when regular treatment and advice from scientific physicians can be obtained free, together with proper prescriptions at the socialized pharmacy? (d) Health Departments, instead of competing with physicians, will become complementary to the socialized physician. (e) Preventive medicine will really be practiced. Since no fee is involved, people will take advantage of regular periodic examinations, as they do of the free medical services of insurance companies. On the basis of one physician to every 500 people, under Socialized Medicine, every doctor practicing in Kings County, for instance, would be placed. There are some 3,500 physicians in Brooklyn, of whom about 500 are true specialists and 3,000 are general practi­tioners. With a population of over two million, there would be place for 4,000 general practitioners and for as many specialists as would be needed. (See also Nos. 21 and 22 following, an Over-production and Distribution of Doctors.) 21. How would Socialized Medicine control over-production of physicians? The law of demand and supply would be the guiding principle. Today, despite all the restrictions governing the study of medicine, there seems to be no way of checking the number of applicants for it. Since every doctor is in business for himself, every student or pros­pective student is willing to take a chance, even if he crowds out someone else, only to find out later, to his sorrow, that he himself has nothing. Under Socialized Medicine, there will no no "chance" for the student to take. He will be permitted to matriculate in such limited numbers only as to supply the natural demand created by the increase of population or increase in work to be done, and by vacancies to be filled. (See No. 22 following on Distribution of Phy­sicians.) 22. How would Socialized Medicine control the distribution of physicians? (1) It is no secret that at present the doctor seeks the larger cities within which to practice and avoids the smaller ones and rural com­munities. No scheme under the present system of practice has been able to solve this problem. (2) Socialized Medicine solves this problem easily. The young graduate will have a choice between (a) waiting without compensa­tion until an opening occurs in a large city, such as might come through retirement, resignation, death, etc. (His appointment might come soon or it might be a year or more); and (b) being placed im­mediately with regular compensation where he is needed, in a smaller city or rural community. He most likely would choose the latter, and once located, the chances are that he would remain. (3) Many men would voluntarily go to the smaller cities, if they were secured with a livelihood and an opportunity to practice medi­cine scientifically. Furthermore, if necessary, compensation might be made more attractive for practice in rural communities. 23. Will Mt politics enter and control the profession in Socialized Medicine? Politics being what it is today, this is a serious objection and must be guarded against. What are the facts? (1) Under Socialized Medicine you would not substitute an evil (politics) for something that does not exist in the present system. Politics cannot be worse under Socialized Medicine than it is today. It is a fact that no doctor can advance much without hospital affiliation. It is no secret that he has to play politics (social, financial, and political) in order to be connected, to advance or to hang onto his position. This is also true of other medical institu­tions, insurance companies, and all forms of present-day contract practice. It is true even of much of our private practice. (2) Let us assume and admit for argument's sake, that the public school system is riddled with politics. Despite that, and as bad as it may be, would anyone advocate the abolition of the system of public education and return to a system where each teacher would practice his or her profession individually? The teachers themselves posi­tively would be opposed to such a proposition. Would it not cost a citizen more money to educate his child? And would the teacher fare as well? The answer is self-evident. (3) The civil service system can be applied to medical practice, is being applied in public medical institutions just as to education, post office, or any other governmental social service. (See PROGRAM of the Medical League for Socialized Medicine, with reference to appointments, promotions and control under socialization.) (4) Here the distinction between socialized medicine and state medicine must be understood. (See Question No. 1.) Both are the same, except, that in state medicine the control is from the top and may be bureaucratic, whereas in socialized medicine the control is determined by the doctors themselves. State medicine would not be true socialization of medicine, just as state education is not true socialization of education. Appointment and Policies are dictated from above. The teachers themselves do not determine policies nor exercise control. The politicians appoint the leaders and superiors and the rest must follow. Despite all this, state education is de­sirable. So, too, even state medicine would be better than private practice. But in socialization of medicine, palicies and control would be in the hands of the medical profession, and politics is less likely to enter. Elections at the medical societies can determine the leaders and the policies, and a democratic control can be easily maintained. 24. Would the community stand for more taxation necessary for socialization? (1) The health of the people is the concern of the people. Health is purchasable and must be paid for by the people. Health is surely as important as education. It seems just to tax the people for education; it would seem equally just to tax them for heaith. Health is being paid for now even through indirect taxation, through public and private charities, hospitals, etc. (2) It is not the function of the physician to advise the method of raising money for the purpose. Whether it be direct or indirect taxation of all the people, taxing the incomes of the higher income group, getting it in whole or in part from the employers, or by some bond issue, is the concern of the people and their legislators. (3) There will be no objection to taxation if only the truth be made known to the people. Such taxation would not be the payment of money for something which they do not pay for now. The people need not pay any more money. If only the same amount, and even less, were spent in taxation that they spend for their inadequate medical care today, it would more than cover the cost of adequate medical care. Ask any man what his annual physician's, hospital, nursing, dental, optician's and druggist's bill amounts to, together with the useless cultist's and self-medication bills, and see if he would object to a tax of '30 per annum. "The people of the United States in 1929 spent ,3,656,000,000 for all forms of medical service. This is approximately '30 per capita per annum." (Wilbur Report). This amount, according to the rc,port, would be ample to cover all cost for the very best medical care, if only correctly applied. Consider that "in the experience of families in the $2,000 to $3,000 income group, living in cities of 100,000 or more people, those families who used any hospital service had average total medical charges for the year of $261, while those that had no hospital care reported total charges of only $67. For families with incomes of less than $1,200 the average hospitalized cost was $67." (Wilbur Report). "Of the $3,656,000,000 spent an­nually for medical service $125,000,000 is spent for services of osteopaths, chiropractors, naturopaths and allied groups, and faith healers, and $360,000,000 for 'patent medicines.' Much of the for­mer and practically all of the latter is wasted.'' (Wilbur Report.) Out of the almost four billion dollars thus spent for all forms of medical care annually in this country, the physicians receive about a b:llion dollars, or only one-fourth of the total, or but twice the amount received by the cults and "paths" and patents. Socialized Medicine would properly apply this amount of almost four billion dollars now being spent annually to give adequate and scientific care to all the people of the land, with adequate compensa­tion and opportunity for service to all the doctors and allied workers in the country, without one cent additional expense. WHY STATE MEDICINE IS NECESSARY By EDGAR SYDENSTRICKER (From Forum, Vol. XC, July, 1933, pp. 47-51.) One of the more ridiculous anomalies of the economic light in the recent reports of the committees on the system which we call "Ameri­can" has been brought to costs of medical care and on medical educa­tion. This particular anomaly may be stated baldly thus: There are about enough doctors, nurses, and others who render or assist in rendering medical services-about a million persons all told-to take care of all sicknesses and do nearly all the preventive work for individual patients that we now know how to do. There is being spent annually by the American people enough money­about three and a half billion dollars-for doctors, nurses, medicines, and all sorts of medical services, good and bad-to purchase reason­ably adequate medical care at current average prices. Yet in a year's time--even in a prosperous era-thousands upon thousands of fam­ilies cannot afford to obtain any medical care; millions upon millions of cases of sickness which ought to have medical attention are un­attended; less than seven per cent of the population have even a partial physical examination and less than five per cent are im­munized against some disease; much preventable sickness occurs and the death rate among adults of middle age is increasing. Although medical science is still far from having solved all the mysteries of ill health, only a little of the knowledge already gained is applied to all the people needing it. A large proportion of doctors and others who apply this knowledge do not receive an adequate or even a decent living income and, with a deep sense of social duty, render much medical service without any pay. This, it is being recognized more clearly than ever before, is not only a ridiculous anomaly but a shameful situation in which to find ourselves. Of course since 1929 we have grown somewhat ac­customed to being ridiculous although unashamed. Nevertheless, according to a well established American belief, it is bad business if one doesn't get paid for what he sells, or doesn't get what he has bought and paid for. According to all canons of social well-being, of sound national policy, and of human justice, something is seriously wrong. It has been wrong a long time, for this situation existed even in our days of riotous prosperity. The inner nature of this anomalous situation of medical care in the United States may be understood better from "case studies" than from statistical tables. Limitations upon space preclude a considera­tion of many cases, but perhaps only a sample is needed. The case presented here is very common, very trite, and altogether lacking in news interest. It must be all of these things if it is to be typical. Furthermore it is an actual case in a smallish city. I touch only upon enough of the happenings to bring a familiar story to the minds of all who read this. When the family physician's diagnosis of John Smith's pain as appendicitis was confirmed by the consulting surgeon, and John was rushed off to the hospital, the family sighed in brief relief that it was no worse. The.customary assurances were given. "Everything will be all right, and he is in splendid shape." "But spare no ex­pense," insisted Mary, the wife. A tense period of waiting followed, for it seems John was caught just in time. Flowers, visits to the hospital, cheery nurses, the surgeon's comments on a beautiful op­eration, promises that John would be home probably within a fort­night, a feeling of deep gratitude-"Thank God it is all over, and he is well rid of a damn nuisance" (that evolution neglected to remove some reons ago) . Then the bills. Six dollars a day for the private room (Mary's idea), laboratory fees, operating room charges, a special nurse for the first day and night. The surgeon had a quiet talk with the convalescent about finances: "My usual fee for this operation is $250 but ..." He was awfully decent about it. The whole business won't cost over $300. John did not have $300 in cash. As a matter of fact, his bank balance when he was rushed to the hospital was $44.24. His salary is $2,400, and his family's annual expenses $2,310 in spite of much budgeting. He has no house to mortgage, and his insurance policy already had been borrowed upon to pay for John, Jr.'s, advent into the world. The new emergency was partially met by getting a salary advance to pay hospital and nursing charges. The family physician and the surgeon must wait. Now John is among those of our middle class who receive adequate care under our system of medical service. His family doctor is an independent entrepreneur. So is the surgeon. Both live on fees from their private practice and are connected with the hospital, members o:f a loosely-knit medical "group" which avails itself of the facilities there. The hospital was built at public expense and shows a deficit at the end of almost every year. These two physicians strictly ob­serve the ethics of thelr profession and are competent private practi­tioners. Both give a considerable amount of free service in the hospital's clinics, do a good deal of "charity" practice outside, charge low fees to some patients, and fail to get paid at all by others. In fact, only a few of their patients pay their fees promptly and in full. The physician's net income in 1928 was $3,100 and the sur­geon's was $5,600. . . • POOR PATIENTS-UNDERPAID DOCTORS Let us put this case history into the statistical picture afforded by the experience of thousands of families. Not all of them involve appendectomies; some are cases of pneumonia, bronchitis, tonsilitis, gall stones, influenza, cancer, intestinal "upsets,'' and so on down the list of human morbidities. Not all of the families are as well off as John's. In fact his position in the economic scale of the popula­tion of the United States can be seen at a glance at the following figures: Per Cent of Families in Each Family Income Income Class Class Under $1,200 15.0 $1,200-$2,000 34.8 $2,000-$3,000 24.6 $3,000-$5,000 15.7 $5,000-$10,000 7.0 $10,000 or more 2.9 This was the economic scale in 1928-near the peak of our wildest financial dreams. The average family had charges for medical care which amounted to $108 in a year and which included not only the occasional "high cost illnesses" but also the costs of frequent and relatively inexpensive illnesses and medical needs-a not unreason­able price to pay for the medical care of a family of four. Families with less than the average income, however, cannot afford to pay th'.s $108. Let us combine the figures given above with some more, .as follows : Per Cent Average of Families Annual in Each Charges Family Income Income for Medi-Class Class cal Care Under $1,200 15.0 $49 $1,200-$2,000 34.8 67 $2,000-$3,000 24.6 95 $3,000-$5,000 15.7 138 $6,000-$10,000 7.0 249 $10,000 or more 2.9 503 Now sickness falls somewhat more frequently and just as un­expectedly upon the poor as upon the well-to-do. Over half of the population gets sick once or more times in a year and the average family has nearly four cases of illness in a year. Yet the average family in the low income class-with less than $100 a month--can actually afford to incur less than $50 a year for medical care as .against $138 in the $3,000-$5,000 class, for example. If they were paupers, they would stand a better chance because the public would foot their bills. The obvious conclusion from these statistics is that the great majority of American families do not get nearly the medical care they need because they cannot afford to pay for medical care when they need it. Let us look at the picture from the doctor's point of view. Such facts as are available show that in 1929 one-third of all physicians had net incomes of less than $2,500; and one-half less than $3,800. If we graded physicians in income intervals of $1,000, more physicians would be found in the $1,000-$2,000 class than in any other. And this was 1929. Of course there were some with incomes of $10,000 or more and a few with $15,000 or more, but we are speaking of the ordinary doctors, in ordinary cities, towns, and country districts. The obvious conclusion from these facts is that the doctors are not getting rich. That is putting it far too mildly, however. When we consider the investment in the doctor's training and his responsi­bility, the inescapable conclusion is that most medical care actually rendered is not being adequately paid for. The underlying reasons for this situation may be fairly summed up in a brief statement of three facts, all of which are involved in the case of John Smith as well as in the statistics: 1. Medical care for nearly all of our population, under the eco­nomic system which we have developed, is a service to be bought when needed. This means that most medical care is produced as an economic "good," has a price, and must be paid for in the market. Four-fifths of the producers are not salaried employees or wage earners; on the contrary, they are professionally and expensively trained entrepreneurs who, within certain self-imposed "ethical" lim­itations, are engaged in business for profit. The greatest opportunity for profit, under existing conditions, is afforded by well-to-do pur­chasers and the competition for profit is active. The business is not profitable except to a few, because of the high cost of maintain­ing many competitive enterprises and because of two other condi­tions, namely: 2. Although fairly accurate predictions can be made as to when and how much of this service is needed by the people in mass, the incidence of sickness in any individual family during a given period of time cannot be foreseen. This means that medical care, especially the most costly care, is a service to be purchased by the individual family in emergencies. 3. Under the American economic system the distribution of pur­chasing power is so unequal that even in most prosperous years, and even if foresight and thrift were common characteristics of human beings, a very great majority of the individual families is unable to provide against these emergency needs for medical service. The economic problem to be solved in the socially essential task of providing medical care to all of the people, thus narrows down to that of adequate payment of those who render reasonably efficient service under an economic system that postulates a grossly unequal distribution, in the population, of ability to pay. This was the problem to which the Committee on the Costs of Medical Care addressed itself some five years ago: Composed of about fifty public spirited men and women representing medical service, public health, various institutions, social sciences, and the public, with Dr. Ray Lyman Wilbur as chairman, and supported by several foundations, the Committee undertook first a series of in­quiries into different phases of medical care and various methods of providing medical care in the United States. The reports upon these studies constitute a valuable library on the subject, probably well worth the three-quarters of a million dollars appropriated to the Committee. That the Committee fully recognized the nature of the economic problem there can be no doubt. "No one fact," it said in its report, "is more clearly demonstrated by the Committee's studies than this one: that the costs of medical care in any one year fall very unevenly upon different families in the same income and population groups. The heart of the problem, therefore, is the equal­izing of the financial impact of sickness." In setting up what is called "a satisfactory medical program," the report contained this admirable statement: If adequate services are available but can be obtained only on financial terms which a large number of persons cannot or will not meet, the problem is not solved. Most communities, in officially assuming at least a theoretical responsibility for the care of indi­gents, have already taken the position that no human being should be allowed to suffer, on account of poverty, from remediable illness or distress. Our present system however, on the one hand lays an unjustifiable burden of unpaid service upon the physician and the hos­pital and, on the other hand, frequently gives the individual of the middle economic level only a choice between becoming a recipient of charity or foregoing needed medical care. A satisfactory program should make it possible for a large proportion of the total popula­tion to pay in full whatever may be charged for needed medical service, on terms which are reasonable and which fully preserve self­respect. The cost of care for those who cannot pay should be dis­tributed, according to ability to pay, over the rest of the community. When the Committee had to face the necessity of proposing a solution, however, it was found that the widely divergent views of its members could not be reconciled. Its final report appeared in No­vember, 1932, peppered with exceptions and objections and accom­panied by two dissenting statements and two minority reports. It contained five principal recommendations which may be summarized briefly as follows: (1) Further local "group" organization of physi­cians, dentists, nurses, pharmacists, etc., preferably around hospitals in the form of community medical centers, or in industrial medical services, or in private group clinics, or in pay clinics, or in county medical society clinics; (2) Further extension of all basic public health services; (3) Placing the costs of medical care on a "group payment basis through the use of insurance, through the use of taxa­tion, or through the use of both"; (4) Formation of agencies by states and local communities for the study, evalution, and coordina­tion of medical services; (5) Better educational facilities for health officers, dentists, pharmacists, midwives, and other personnel. Thus the Committee apparently was more concerned with improve­ment in the quality of medical care than with the heart of the prob­lem, the consideration and possible solution of which was the primary purpose of its work. Improvement in medical care is of course, highly important but the pressing problem is making what medical care we now have available to all the people. For the solution of this, the Committee went no further than to propose an experimental development of various forms of local community facilities for medical care through the future organization of group medical prac­tice with local, state, and federal financial aid where necessary, pos­sibly supplemented by voluntary health insurance among "organized groups of consumers" if any such groups should desire it.1 No definite, comprehensive, nation-wide, or even state-wide plan emerged from this five years of study and deliberation. The Ameri­can Nation was advised to wait until the thousands of its communi­ties would be sufficiently aroused to solve their own local problems. The buck was passed, in effect, to social evolution. A PROGRAM OF STATE MEDICINE The situation is one that calls for a definite program of action upon a large scale, especially in a period when the ill effects of industrial and agricultural maladjustments upon the health of many will be manifested. We are not dealing with a matter of minor importance. Nothing less is at stake than the public health itself which, as Disraeli said many years ago, "is the foundation upon which rest the happiness of the people and welfare of the state." The end of any effective attempt to solve the problem before us should be nothing less than to make it possible for every person to obtain such medical care as we now know how to render. This medical care should be provided and must be paid for. If I were to outline even roughly such a program, I would say that its scope should not be less than state-wide, although its develop­ment in some localities may be slower than in others; that all kinds of medical care at home or in institutions should be provided; and that those who receive this care should include not merely those who are employed but all persons and their families having incomes below an amount sufficient to purchase medical services in any contingency. We should go l;>eyond the health insurance systems of Great Britain and Europe which provide financial assistance, and in some instances medical care also, to employed individuals only, and we should go further than to provide public medical service for infants, children, and mothers, or for tuberculosis and mental diseases. In such a program the maintenance of the physician's professional freedom is of cardinal importance; adequate remuneration of all who render 1Against the form of local "socialization" of medicine proposed, representatives of organized medicine on the Committee vigorously registered their dissent. Althouiih not convinced that insurance was a good method of equalizing the impact of sickness, they pointed out that "if we adopt in this country either of the methods tried out In Europe, the sensible and logical plan would be to adopt the method to which European countries have come through experience, that is, a compulsory plan under govern­mental control." Some of the members signing the majority report expressed t!temaelves as In favor of statewide compulsory health Insurance for certain population c.roups. medical service is necessary; and the promotion of higher quality of medical care, the professional administration of professional per­sonnel and activities, the maintenance of the private relationship between physician and patient, and the patient's free choice of phy­sician are obviously essential. The Committee on the Costs of Medical Care came to the con­.clusion, quite rightly, that the costs of medical care should be placed on a "group payment basis through the use of insurance, through the use of taxation, or through the use of both." Insurance is a well-established procedure of distributing costs; taxation for main­tenance of health is in accord with the thoroughly well-recognized principle, so succinctly expressed by Dr. William H. Welch the beloved dean of American medicine, that "there is no more important function of government than the prevention of disease, the protec­tion of the health of the people." Yet, strangely enough, the terms "state medicine" and "com­pulsory health insurance" incite some to unreasoning fury. In facing a problem which concerns the health and happiness of the entire population, it is perhaps not impertinent to suggest that the time has come when we should cease to listen to any except those who are willing to think about the matter dispassionately, and, it might be added, unselfishly. For no one, unless he is hopelessly timorous or narrow-minded, should refuse to consider frankly and without prejudice, any procedure, no matter how radical it may seem at first glance, which can be utilized in dealing with a social problem. The distribution of the costs of medical care among that moiety of the population which is able, or partially able, to pay but cannot meet emergencies is clearly a situation to which the well-established methods of insurance ought to be applied by the government as sound business procedure. All experience points to the desirability of the compulsory form of insurance as well as to public control of its administration, including the collection of the insurance pre­ miums. But the compulsory health insurance can only be a partial solution for several reasons. One is that the proportion of our popu­ lation which is indigent or which is on an economic level so low as to preclude the payment of all of the insurance premiums, obviously cannot be provided for by the insurance method; this proportion varies greatly with the ebb and flow of "prosperity." Another reason is that there are many rural areas in which not only many of the population are unable to pay insurance premiums but medical per­ sonnel and facilities are seriously lacking. Furthermore, there are certain types of sickness for which the insurance method is not easily applicable. Communicable diseases, for example, properly are a menace to the public and their preven­tion as well as care properly constitute a public function. Tubercu­losis, cancer, orthopedic defects, syphilis, are matters not only for public concern but require expensive treatment far beyond the ability of the ordinary individual to meet or a strictly insurance system to provide for. Hence, recourse must be had to public sharing through taxation of some of the costs. In fact, taxation is already being relied upon more or less generally to meet (a) all of the costs of medical care of the indigent and of residents of communities where private facilities and personnel are not available; (b) most of the costs of more expensive services rendered to the low-income classes; and (c) the costs of highly specialized treatments for certain types of cases and of preventive care against certain diseases. It is safe to predict that in the coming period of economic readjustment, these types of public medical service will be developed to an increasing extent. It is the logical solution of these particular problems, whether some of us like it or not. Public medical service along these lines and compulsory insurance against the costs of other medical care are to be regarded as com­plementary parts of a state-wide system of paying for medical care. The rendering of medical services obviously must be done by physi­cians according to standards and in ways deemed by them to be most satisfactory and efficient, but the medical, nursing, and dental professions will fail in their duty unless they cooperate in develop­ing a program whereby all of the population can be served and a situation be more adequately met--a situation which, to reiterate, is a ridiculous economic anomaly as well as a menace to public welfare. A STATE-OPERATED SYSTEM OF MEDICAL SERVICE FOR TEXAS By DAN R. DAVIS Department of Rural Sociology, Agricultural and Mechanical College of Texas Dr. Albion Small, an eminent sociologist, after many years' study of man's primary interests and desires, has concluded that the number one interest of mankind is health. The State and our Nation have given us a free public education system instead of required tuition, free use of public highways in place of the privately owned turnpike, and a low-cost government­operated postal service has supplanted the costly service of the pony express. However, it seems strange that our State and Nation have done these things with little regard to a program for making health services free to man. A free education housed in the mind of an unhealthy body is a poor investment. Free housing, bedding, and food are available in a substantial building to every rural or urban man and woman in all countries and parishes of the United States--the county jail. These same free facilities are not, available to all the sick and bedridden. Limited forms of charity m larger cities· make available some free health treatment to a small per cent of the very poor residing in slum areas. The millions comprising a low-income group in our rural areas are denied even this limited health aid of urban charitable institutions. Texas and the South are primarily rural. The farming millions of our Nation, many of which are farm tenants, received only 8.9% of the national income in 1937. The costs of private medical service concentrated in the city, bear most heavily upon the shoulders of the isolated low-income groups of rural areas. These costs of private medicine are highest for those least able to pay for medical services. Even the country doctor whose services are not free is rapidly dis­appearing, and all types of commercial health facilities in rural areas are becoming less available to our farming class in spite of the fact that recent government health surveys reveal "the poorest people are sick more." The National Emergency Council states that two millions in the South alone are infected with malaria annually and that other millions need treatment for pellagra, hookworm, and malnutrition. Paul De Kruif has written in "Why Keep Them Alive?" that over one million one hundred thousand babies die preventable deaths each year within the borders of the United States. This is ironic in a democracy of magnificent hospitals and trained physicians. De Kruif states that the deaths of these infants are due primarily to the economic inability of parents to provide adequate health treat­ment for their offspring. It is indeed a serious matter when life and death are weighed on sinister economic scales by those who have and those who have not the ability to pay for health services. Miss Roche has presented the following facts from The National Health Survey: "1. Four millions or more people are disabled by sickness in the United States each day of the year. "2. In 1936 nearly one-quarter of a million women did not have a physician's care at childbirth. "3. Infants in families with an annual income of less than $500 die at a rate of 168 per 1,000 live births, as contrasted with 30 per 1,000 in families with incomes of $3,000 or more." These are some of the principal charges of organized private medicine in its objection to a program for state free medical services: I. STATE FREE MEDICAL SERVICE IS SOCIALISTIC "Socialism" was the charge hurled fifty years ago against those who fought for a free education system and a free system of public roads. We, today, however, do not think of our public schools and public roads in terms of socialism. We are following the philosophy of Thomas Jefferson who inferred that the greatest good should be for the greatest number of people. II. STATE FREE MEDICAL SERVICE WOULD DESTROY PRIVATE MEDICINE SINCE ALL DOCTORS WOULD BE EMPLOYED BY THE STATE "Destruction of education in Texas by the State" was another false accusation used by those who fought the movement for a free system of education. After all these years, the individual still has the choice of attending a private school of primary, secondary or university rank or one may attend a State supported institution of similar educational levels. Under a program of free medical service all doctors would not be regimented by the State nor would all doctors be employed by the State--heaven forbid. The individual would have the opportunity to continue receiving the services of his private family physician at a personal cost if he so desired. The State would furnish free medical service to those who are unable to pay for a private doctor and hospital services. In other words those able to pay for medical services personally would still have the freedom of choice in the selection of a physician. Whereas, a system of State medical service would be available to the poor and rich alike. III. STATE FREE MEDICAL SERVICE WILL DESTROY THE INITIATIVE OF THE PHYSICIAN SINCE HIS ECONOMIC INCOME WOULD BE DIMINISHED IN COMPETITION WITH THE STATE It is revealed in a study by the Extension Service of the University of Wisconsin that in the prosperous days of 1929 for every doctor who received a salary of more than ten thousand dollars, there were two who received less than twenty-five hundred dollars. We can readily see that all physicians in private practice are not "getting rich"-as many doctor bills must be "marked off" the books, uncollected, and many charity cases in cities are performed by some physicians without economic compensation. Under a system of free medical service physicians would be paid a guaranteed salary by the State-there would be no worry of uncollected bills-nor would the doctor be requested to perform for charity. Under a State program there would be no charity cases. The proposed system would lighten the burden of the over-worked, but socially-minded private physician who gives some free service when time permits him to perform charity operations. The salary schedule of doctors employed by the State would be scaled on the basis of training, ability and experience of the indi­vidual. The guesswork involved in the present hiring of a private physician would be removed under a system of State medicine as only the very best physicians would be employed by the State and the unscrupulous system of fee-splitting would be eliminated. State-employed physicians would be given continuous training in service and frequent examinations would test and measure the ability of those serving the masses. Too frequently the public is compelled to endure outmoded medical practices in the hands of private medicine. The State of Texas and the Federal Government employ today only the best prepared veterinarians at a scaled salary for protection of the livestock industry of our State. Many of these veterinarians as well as many present-day physicians are trained in State-supported institutions of higher learning. However, Texas is offering free medi­cal attention only to her livestock and diseased agricultural crops. IV. STATE MEDICAL SERVICE WOULD DESTROY ALL MEDICAL RESEARCH Many of the greatest research laboratories of this generation are State and Government supported. The work at the State Agricultural Experiment Station is an example of the wonderful research being done by this means of support. Most present-day medical research has to depend upon the precarious economic support of private dona­tions or endowments. The State would be more able and certain in supporting medical research and the scientific findings would be made available and free to the public-as are the present-day findings made free to the public in the instance of agricultural research. Thus a State-supported system would stimulate the present slowness in advance of medical science. V. POLITICS WOULD POLLUTE A SYSTEM OF STATE MEDICINE Texas has an excellent State-supported school system. Texas has one of the finest public highway systems in the United States. Texas has a well-trained and efficient State Ranger force and State Highway Patrol. Texas has the largest State Agricultural Extension Service and State Agricultural Experiment Station in the world. We have an excellent State-operated institution for training medical students at Galveston. These accomplishments have been made in spite of politics in Texas. There is no reason for Texas not being able to have a politically untarnished system of free medical service since all physicians employed by the State would be compelled to meet the requirements of a civil service examination as one of the prerequisites to employment. Another important argument for the establishment of a free medical service is that a program for sickness prevention would be put in vigorous practice. The Extension Service of the University of Wis­consin reveals a very lop-sided picture in pointing out that only $1 out of every $60 spent for medical service goes for the prevention of ill health. Private medical groups do not have the time nor money to sponsor an educational program for the public on the most effective means of dealing with sickness-the prevention of sickness. A considerable portion of the program of State medicine would be directed in the education of the public on the prevention of sickness and disease at a saving of worry, illness, human lives, and money to the patient, to the State and to society. This portion of the program would also save the ill effects and money wasted .on harmful patent medicines by many of our rural population, who cannot economically afford the attendance of a physician under the present medical system. We may further our argument for a system of free medical service with these concluding statements: 1. State medicine would eliminate much of the overlapping of medical service now existing. 2. The cost of medical education would be decreased. 3. Adequate salaries would be provided all doctors. 4. There would be a better distribution of medical facilities in both rural and urban areas. 5. Work in preventive medicine would be extended. 6. The State would make latest scientific equipment and discoveries available to all doctors. 7. State medicine has succeeded in foreign countries. England, France, and other European nations have government programs to meet the health needs of all their peoples. We, in Texas and the United States, lag in this field of social and economic legis­lation for human betterment. WHO SHOULD PAY THE DOCTOR? THE GROUP By WILLIAM TRUFANT FOSTER Director, Pollack Foundation for Economic Research. (Reprinted from Rot..ria,. Maotu:ifte, Nov. 1986.) Only the rich and the poor, it is said, get the best of medical care; the rich because they have money, the poor because they have charity. So if you are rich or poor, you may not be interested in new efforts to provide good medical care for everybody. Possibly, however, you are one of those (in the United States, 100 million of the 125 million population) not rich enough in cash to pay a $500 hospital bill, or poor enough in spirit willingly to accept charity. If you are rich, I said, this may not interest you. I take that back; for, whether you know it or not, you now pay some of the doctors' losses on the millions of patients who do not pay their bills at all. At this moment in America, over 40 per cent of doctors' bills are six months overdue. Most of these bills will never be paid in full. Certainly you are interested in plans which may enable some of these millions of patients to meet their own bills. If you are poor, I said, this may not interest you, since some of the poor get the best of medical care in free clinics. I take that back, too. You may resent being a charity patient. You always expected to carry your own weight. Perhaps a calamity came­paralysis, lead-poisoning, or a crashing of automobiles. Suddenly you found yourself overwhelmed with doctors' bills, nurses' bills, and hospital bills. For the first time, you belonged to the 10 per cent who, in any one year, bear 41 per cent of the Nation's bills for sickness. To make matters worse, your wages stopped precisely when your expenses increased. Certainly you would like to know whether it is not possible, by paying moderate fees in advance, to insure against such crushing, unpredictable costs. You know what happened to your neighbor, Henry Brown. You know his family tradition of self-reliance; how he always prided himself on paying his bills promptly. Then came that baffling illness. He went from one specialist to another. Now, his savings gone, his job gone, and his wife broken down under the strain, he is mentally losing his grip. And he does not yet know what actually ailed him. Suppose that Henry Brown, by paying a monthly fee within his means, say two or three dollars, had been entitled to the diagnostic services of a fully-equipped group clinic and free hospitalization. Could this family tragedy have been prevented? Perhaps not, but the question is worth discussing. Would his peace of mind concerning expenses have aided his recovery? Very likely, it would have. Suppose, further, that the group clinic of which Henry was a member had induced him to have a thorough health examination every year. Might his illness have been prevented? Again, perhaps not. Every doctor knows, however, that a large proportion of illnesses are preventable, if treatment is given in time. Yet, as a means of prevention, how many Henry Browns in your town have had a thorough examination this year? Not one in ten, if your town is typical. Should we not pay doctors to keep us well, instead of paying them when we are sick? And would not doctors gladly try to keep us well, if collectively we paid them flat salaries to do precisely that, and if, when we became sick, they received no more pay, but only more trouble. Incidentally, can we not cut down the Nation's sickness bills by spending more of our tax receipts on prevention? We, of the United States, now spend every year for medical care over three billion dollars, yet only one dollar out of every 30 goes to public health services for the prevention of disease. The other 29 dollars are spent in trying to cure disease. Every collection of statistics in the field of medical economics reveals our collective stupidity. Henry Brown's community is typical-and therefore stupid-in another respect. There was a fully-equipped private hospital only seven blocks from Henry's home, with one bed out of every three unoccupied. Henry needed the hospital; the hospital needed patients. Can we not find a way to use our hospitals? And our nurses? And our dentists? And our technicians? Many, many of them now spend a large part of their time waiting for patients who simply don't come. Under our traditional fee-for-service regime, our failure to pro­vide medical care for all the people is a national disgrace. We have relied on rugged individualism; we have left the doctors alone to solve the problem in their own way. As a result, progress in the science of medicine has been almost miraculous, while progress in the economics of medicine has been intolerably slow. The Committee on the Costs of Medical Care, which spent, directly and indirectly, over a million dollars to find out the facts, concludes that our tragic failure to use our resources causes a vast amount of preventable physical pain, mental anguish, needless deaths, and economic waste. More than 50 million persons in the United States during the current year either are not receiving the care which they need, or are burdened beyond endurance by its costs, while many thousands of practitioners are underemployed and poorly paid. The New York Academy of Medicine says that more than half of all deaths at child-birth which could have been avoided are caused by deficiencies in medical care. A study of industrial workers in certain areas by the United States Public Health Service shows that over half the sick receive no medical attention whatever. In any one year only about 30 per cent of the teeth which need care receive care: the rest just keep on decaying. Meantime, the United States leads the world in dental science. Not more than 8 per cent of the population have an annual health examination, yet that is an abso­lutely essential part of any program for the prevention of disease. Our army tests reveal the unhappy results of this neglect. Rugged individualism, it seems clear, has left us millions of far from rugged individuals. This would be deplorable even if it were not possible to provide everybody with good care; but it is possible. We know how to do it, and we have the resources, human and material. The failure cannot be ascribed in any considerable degree to individual practitioners: they are able and willing to do their part. The chief trouble is the complacence with existing conditions which is shown by some-not all, by any meanS---Of the organized branches of medicine. Since, then, we are fully equipped to solve the problem, why do we not solve it? To the man in the street the answer is plain. It is because we have not yet provided ways of paying the bills. The problem therefore is to free the science of medicine from the shackles of the business of medicine. How can we do that? Chiefly, a majority of the Committee on the Costs of Medical Care concludes, through group practice of medicine and group payment for service. The Committee recommends that medical service, both preventive and therapeutic, should be furnished largely by organized groups of physicians, dentists, nurses, pharmacists and other as­sociated personnel. Such groups should be organized, preferably around a hospital for rendering complete home, office and hospital care. The form of organization should encourage the maintenance of high standards and the development or preservation of a personal relation between the patient and his physician. The Committee recommends further that the costs of medical care be placed on a group payment basis, through the use of insurance, through the use of taxation or through the use of both these .methods. This is not meant to preclude the continuation of medical service provided on an individual fee basis for those who prefer the present method. The Committee recommends that the study, evaluation and coordination of medical service be considered important functions for every state and local community, that agencies be formed to exercise these functions, and that coordination of rural with urban services receive special care. The Committee's proposal to distribute the risks of patients by means of insurance is an obvious way out. Insurance is indicated because costs of sickness like losses by fire fall so heavily, in any one year, upon so small a proportion of the population. In any one year, the most unfortunate 5 per cent of your family pay 19 times as much per family for medical care as the most fortunate 70 per cent and in any one year only one person out of fifteen needs hospital care. But no family can be sure in advance whether, in a given year, it will fall in the lucky 70 per cent or in the unlucky 5 per cent. The costs of illness are unpredictable and therefore cannot be budgeted by the individual family. Already group practice in 50 different communities has enabled members of the groups to get good medical care for less money, partly because under the group plan the time of doctors, dentists, nurses and other members of the staff is used to advantage. The Committee on the Costs of Medical Care presents nothing more i·evolutionary than the proposal that such experiments in groups _practice and group payment as are already under way should be tried out wherever the people of a community wish to try them. Yet this mild proposal is condemned by the Editor of the Journal of the American Medical Association as "Socialism and Communism-incit­ing to revolution." The American Medical Association, moreover, at its annual convention last year [1934] in Cleveland, Ohio, went so far as to pass a resolution declaring that "however the cost of medical service may be distributed, the immediate cost should be borne by the patient able to pay at the time the service is rendered." This absolutely shuts out all pre-payment plans. It condemns group payments on an insurance basis. If it means what it says, it condemns any doctor who accepts a salary for his services from a group of patients. Thus the American Medical Association reiterates its assertion that those who pay the bills for medical care have no right to say how the bills shall be paid. For years, the American Medical Association has repeatedly as­sured us that it favors experiments toward more satisfactory methods of paying for medical care; but to date it has not advanced any far­reaching plans of its own, and when any group outside the Associa­tion, such as the Ross-Loos group in Los Angeles, starts an experi­ment, those in control of the profession respond by trying to excommunicate the cooperating doctors. But, we are told, group practice "destroys the precious personal relation between the patient and his family physician." I do not find this the case among the many patients with whom I have talked in Los Angeles group clinics. Each patient selects his own physician from a panel, and this physician has continuous charge of his case. The satisfaction of the patients is shown by the rapid increase in the membership. Why, in any event, should the fact that the physician is sure of bis pay be a barrier between him and his patient? The bills are not among the "precious personal relations" between the doctor and the patient. On the contrary, the bills are the chief cause of friction. Moreover, under prevailing individual practice, millions of men, women, and children have no relations, personal or otherwise, with a family physician, or with any other kind; and it is primarily for some of these uncared for millions that group plans are proposed. Any proposal whatever for collective attack on the problem is at once condemned as "state medicine," or as a step toward "state medicine." Inevitably, so it seems, collective action means that the expectant mother cannot be confined except by vote of the Board of Aldermen. But why these sudden fears of political control of medical practice? Those who view with alarm all new adventures in medical economics seem to overlook the fact that already we have collective control of the economic phases of much medical practice. That is to say, we now care at public expense for war veterans and for the army and navy, as well as for those who suffer from mental disorders, from tuberculosis, and from a great many other diseases. Also, collectively, we furnish free medical care for the indigent and do most of the work for the prevention of contagious diseases. Most of the hospital beds, too, are in public institutions. In fact, above 15 per cent of the national bill for medical care is paid from public funds. To date this is our answer to the contention that medicine has a right to control its own affairs. To this extent we have re­nounced rugged individualism. To this extent we already have state medicine. If this is "Socialism and Communism-inciting to revolution," even the 100 per cent patriots need not be alarmed. For it has gained no votes for either the Socialist or the Communist party. Whether or not we shall have state medicine is the national debate proposition selected this year [1935] for the high schools and dis­ cussed by more than 50,000 students. It is largely an academic question. In point of fact, the scope of state medicine is increasing, but not so rapidly as the scope of private medicine administered by groups and paid for on a monthly fee basis. It is the old individual fee-for-service kind of practice that is losing ground. Those of us who are promoting group practice plans are doing far more than the organized medical profession to curb the growth of state medicine. Yet, in opposition to all plans proposed by laymen, the organized profession asserts that medicine has a right to control its own affairs. This is a naive conception of its place in the social order. No profes­sion has any rights which are not conferred upon it by society. The county medical association which solemnly warns us that no govern­ment organization has any right to assume the responsibility for the prevention of disease merely makes itself ridiculous. As a matter of fact, the medical profession is the only one that persists in such an untenable position. Railroads, insurance companies, bankers, public utilities, stock exchanges, contractors, engineers, lawyers all know that they can expect to be left alone, only in so far as leaving them alone conduces to the public welfare. Even with the present national income the people of the United States are able to pay for adequate medical care. To be sure, once we contrive to make the flow of money to consumers keep pace with the flow of consumers' goods to market, we shall more than double our national income. But the present income is enough to provide good medical care for everybody. Thirty-six dollars a year per person would be enough, if we abolished the reducible wastes of present unbusiness-like methods. Already we are spending about $30 a year per person. An in­.crease of $6, if the funds were spent to advantage, would meet all needs. This means that we could give 120 million people the bene­fits of the astounding advances which have been made during the past generation in medical science, if we spent for medical care, all total, merely as much money as we spent, in the darkest days of this depression, for trivial things. NEGATIVE READING MATERIAL THE PRESENT STATUS OF TEXAS MEDICINE* By E. W. BERTNER, M.D., Houston, Texas (From Teza.s Sto.te JournaJ. of Medicine, June, 1939.) Ladies and Gentlemen of the State Medical Association of Texas: Let me reassure you that this is not intended as a political or propa­ganda tirade, nor shall I bore you with inconsequential medical statistics or platitudes. On the other hand, an interpretation of the present status of Texas Medicine cannot escape a brief scrutiny of social, economic, and political trends which so obviously affect the practice of medicine in Texas. Today the Texas doctor stands in stark and cold bewilderment before a political expediency which proposes to make his profession a State utility and reduce him to the status of a political automaton­a political expediency which warns him that if he is dissatisfied or protests, taxpayers' money will be used to subsidize new men, trained to a proper subserviency to political overlords. The attempt has been made to create the impression that American medicine is inadequate; that a crisis in medical care is imminent; and that the situation can be met only by discarding self-reliance and self-help and substituting for them State Medicine. In reality this is merely a repetition of history. Bismarck rode into German political power on the expediency of State Medicine, which promised the will-o'-the-wisp delusion of "free medical care." With the world wallowing in the mire of antedeluvian economics, maladjustments, and experimental government-while barbaric wars smoulder over half its population and its people shudder in antici­pation of sudden death from the sky-a world-wide hysteria has disorganized business and bewildered industry. In our own country, agriculture is facing a staggering loss, labor is restless, jobs are insecure and twelve million people remain unemployed. Two gigantic oceans protect us more or less from foreign inva­sion. On the other hand, instantaneous communication has brought us inevitably under the influence of foreign suggestion and propa­ganda. Is it any wonder, then, that a keyed-up Nation of intelligent •Pr..,ident's Addrms delivered at the Opening Exercises of the State Medical Asso­ciation of Texas, San Antonio, Hay 9, 1939. people can be stampeded by a fantastic radio dramatization of a mythical Martian invasion? Out of just such economic disorganization and national tension came dictatorships and tyranny for Italy, Germany, and Russia. In the United States, foundations are already laid for steps leading to dictatorship. In other countries, steps that led to dictatorship looked harmless. They were subtle and insidious. No people ever knowingly or willingly bow to tyranny. Tyranny is forced upon them by easy stages and becomes a reality before anyone is conscious of it--even the dictatorI National unrest has resulted in a critical scrutiny of business and the professions. Human endeavor presents many facets, of which the art and science of medicine is only one. If we look around the corner at the other man's activities, we will find them reflecting the same light of human hope and inspiration---only from a different angle. Standing on the sidelines, it is easy to criticize any business or profession. One may revel in the breath-taking beauty of the stage setting behind a scintillating prima donna, yet no one thinks of turning back stage to point with diabolical rapture to the uninspiring props, the ugly ropes, and the cast-off accessories. Yet this is exactly what professional politicians have done to medicine. By subtle inuendoes they have claimed that physicians have failed in the private field and that to safeguard the health of the Nation, the Government should step in, take charge of the doctor and his patient, plunging both into National, State, and local politics. The politician has pointed to the increasing incidence in industrial disease, traumatic injuries, insanity, venereal disease, and maternal sickness and death. Every doctor knows that there are medical problems unheard of a decade past. He knows it, and is far more deeply concerned than any politician scrambling for a few votes. But let me show you just how such problems have come about: Picture, if you will, the Texas of a century ago, when fourteen Texas doctors fought in the immortal battle of San Jacinto, and shortly thereafter when one of them, Dr. Anson Jones, the last president of the Texas Republic, spoke the last word in independent Texas history. Population was sparse. Transportation was confined to rumbling stage coaches and the scurrying of pinto ponies. Countless buffaloes and Indian tribes roamed the rolling plains. Culture moved at a slow pace. Wants were simple, requirements for happiness were simple. The lofty ideals and indefatigable spirit of the pioneering doctor were just becoming a definite part of the new country. The pioneering doctor had come to Texas. He saw it start. He participated in the conquering of new frontiers, and the settling of thousands of Texas communities. He gave his time and talents devotedly in his professional sphere. His life pattern is indelibly woven in Texas history as a medical philanthropist who growled away the fears of mothers, cursed sympathetically with harassed fathers and cried softly with little children. Then came the "iron horse" to open up the vast store of natural resources of a great State and make them available for industry. Life speeded up with ever-increasing crescendo. Apache trails gave way to an intricate network of platinum high-speed highways. The ghostly shadows of kerosene street lamps were replaced by phosphorescent carpets of electric lights. The quiet whisper of the country village became indeterminate in the robust and virile voice of the growing metropolitan center. The cross-pattern of Neon lanes roared with the hum of machinery and the blatant noise of modern industry. Suddenly things began to happen. An agricultural Nation became an industrial one almost overnight. The transition brought a horde of unpleasant things, such as labor disputes, sit-down strikes, hunger, unemployment, and industrial disease. With the advent of the a.utomobile the highways became filled with hurtling tons of mobilized steel, and a casualty list of dead and wounded resulted, comparable only to an army during war. The radio ushered in an epoch of nerve-shattering, moaning psychopathic music. Movies and endless periodicals displayed lurid scenes and photo pictures that constantly stimulated the impressionable to a dangerously high emotional pitch. The man on the street began to clamor for the inalienable rights of "life, liberty, fmd pursuit of happiness," without the realization that only that becomes real or helpful which has cost the sweat of his brow, the effort of his brain, or the anguish of his soul. Modern living brought about the illusion that short cuts to happiness can be had. Like all illusions, the end was loss of reality, failure, and misery. And thus nervous and mental disease, as well as wear-and­tear heart diseases, began to increase. Yes, we have been at great pains to construct devices and machinery to be energized by steam and electricity and sunshine, without realizing that the human personality must, too, make a proportionate adjustment. We have emancipated ourselves from the trials and tribulations of the pioneer but are still wandering about in the jungle, dissatisfied, hungry, making occasional excursions into paganism, and experiment­ing with all manner of eccentric cults, longing for the spiritual equivalent of our repudiated antiquity. The point is, the doctor has nothing to do with the growth of industry, with its accompanying occupational diseases; an increase in the number of automobiles with a gigantic casualty record; modern bad habits which disseminate diseases of venery; or the inadequate development of potential mothers who grow up behind sodium stained window glass that filters out ultra-violet light, and who eat hasty lunches to the detriment of their nutrition, with an inevitable increase in maternal and infant morbidity and mortality. The doctor is and always has been deeply concerned with the inevitable consequences of human misery and maladjustment. Human misery, in whatever form, may be a symptom, a cause, or an effect. It is an expression of degeneration, and therefore an indication of mental and spiritual decay. It is a cause of weakness and discourage­ment, and therefore of further degeneration, and behind personal degeneration lies a multitude of causes far removed from the practice of medicine. What, then, is the reason for the deluge of ill-advised criticism of medicine and radio dramatizations which picture the doctor as a hybrid Frankenstein creation, and which blame the profession of medicine for everything from Adam's misadventure in the Garden of Eden to the late plundering of Czechoslovakia by a German megalo­maniac? It may occur to you that I am over-sensitive concerning Texas Medicine. If so, then recall that one of our Texas county medical societies, together with a medical society in Washington, and the American Medical Association, were hailed before a Federal grand jury and accused of criminally infringing upon the anti-trust laws. An Assistant District Attorney released to the press, with resulting widespread publicity, a statement implying the guilt of.the defendants. One of his assistants made speeches from public platforms, stating that the litigants and their officers were criminally guilty. The litigants and their officers were subjected to the income tax investi­gation. On December 21, 1938, presumably influenced by the propa­ganda of the Department of Justice, the Federal Grand Jury voted indictments against these medical associations and nineteen indi­vidual physicians. In the meantime, the litigants were threatened with the withdrawal of Income and Social Security tax exemption-as a non-profit, scientific educational foundation-possibly retroactive for a period of ten years. Then, facing these defendants with the possibility of ruinous taxes, jail sentences and heavy fines, the Assistant District Attorney was in a position to say to them: "If you will do what I tell you to do; agree to refrain from doing what I do not want you to do (concessions far beyond illegal practices) , I will ask the court to enter a decree, dismiss the case, and you will not have to go to jail or pay a fine." The doctors refused to consider the proposal. This intimidation means that if associations and individuals can be coerced on such a basis into concession "far beyond illegal prac­ tice," every association and business can be placed under executive control, regardless of existing practices, statutes, or constitutional rights. This pierces the heart of the enterprise system, and is the most sinister menace that has confronted medicine, as well as busi­ness and industry in the United States. It seeks to seize control by the blackjack method of threat and coercion. Newspapers throughout the United States carried statements attributed to the Assistant District Attorney that if 150 additional attorneys were placed at his disposal, he could reach every business and industry through Federal Grand Jury indictments. Thus, consent decree coercion is not the concern solely of the physicians or of medical associations. It is as vitally important to business and industry and the individual citizen. They stand next in line. Timed with unusual political perspicacity, the National Health Bill was introduced by Senator Wagner. The subtle and adroit National Health Bill does not provide for any new Federal agency. But in its unregulated grant of power and its authorization of expenditure without limit, it is as dangerous a piece of legislation as has ever been proposed in Washington. It is vague, wasteful, and unscientific. In some respects it is so simple as to appear innocuous. Its grants-in-aid to individual states for specific purposes are in effect pre-dated blank checks upon the future. On the basis of the administration's billion dollar thinking and expenditures, the actual appropriations do not seem unduly large, but each section carries provisions for unlimited expenditures once the machinery is established. On the basis of the rate of progression established, the total cost would exceed two billion dollars in 1945, with no limitation on expansion. Every dollar of State expenditure for medical services would be subject to the approval of some Federal department or bureau labor or treasury departments, or the Social Security Board. And the larger the State outlay the more can be expected from the Federal treasury. Worse still, the Federal agencies at their discretion may allocate funds to the states on the basis of population or of "financial resources of the State." You may well ask yourself, why all this political skirmishing? Why has the medical profession been indicted, intimidated and threatened? The reason is simple. Last July, a National Health Conference was held in Washington, attended by representatives of labor, welfare agencies, medical organizations, social workers and other groups. From that con­ference there emanated a so-called "National Health Program," which had been developed by the Inter-Departmental Committee to Co­Ordinate Health and Welfare Activities, by authority of the President of the United States. Five specific proposals were made: 1. Expansion of public health service. 2. Increase of all hospital facilities. 3. Medical care for the medically indigent. 4. A general program for medical care. 6. A program for compulsory sickness insurance covering the entire population of the United States. The first four of these proposals were accepted by the American Medical Association. As a matter of fact, they had always been the objectives of medicine. The last was and still is violently opposed by a very great majority of physicians. Time and space does not permit an analysis of the doctor's objection to compulsory sickness insurance. Suffice it to say that compulsory health insurance takes away initiative; fixes permanent limits to the strata of the people; prevents their rise to better comfort levels; is an unbearable and unjustifiable tax burden ; offers poorer medical service than we now have; does not enhance preventive measures; creates a medico-socio-political machine. For the medical man it would provide a degree of security but no career, and would fix him also in a given income group for life. And worst of all, it would make a politician out of himI It so happens that the doctor occupies a position that makes him potentially the most effective of political agents. It has been said that at some time or other a doctor enters every home. He enters it during a period of emotional stress. His relationship is a confi­dential one. If you make him dependent for his livelihood on the whims and fancies of city hall or county courthouse satellites, he cannot but bow to a political intimidation which cannot fail to use him for political propaganda. And this, my friends, is the status not only of Texas medicine but of American medicine. It stands at the cross-roads and trembles in the balance. It is a question whether we will have individual medi­cine as practiced in America at present or socialistic medicine as practiced in Russia and Germany. No historian will deny that the history of medical progress from Hippocrates to Osler is a history of individual achievement. History shows that from the jungles came the medicine men, from the battle­fields came the crude traumatic surgeons, and from the slums of the Old World came the midwives-all bringing with them experience steeped in prejudice and perversion. Here and there, like a brilliant comet, there has fl.ashed across this human drama one of these great medical individualists, who has spun these polyglot experiences into the warp and woof of medical science. This weaving has not been done by communism or socialism or fascism or by medical bureaucracies, but by great minds stimulated by the prize of conquest. Medical progress comes only from human wisdom-the deep knowledge that grows from being continually exposed to the pitiful frailties of mankind. This wisdom springs inherent in your Texas doctor. There is an ineffable value in his human touch that transcends all legislation which seeks to dip its partial fingers into the sterile waters of the healing art and arbitrate over his mission of mercy. The price­less human bond that exists between him and his patient can never exist between a medical politician and a patient with a government number and a red-taped record with no significance! This is the status of Texas medicine. MEDICINE IN THE CHANGING SOCIAL ORDER* IRVIN ABELL, M.D. President, American Medical Association, Louisville, Kentucky In the changing social thought of the last few years much has come about that is at wide variance with what heretofore had been regarded as fixed and established. Industrial disability compensation, unemployment compensation and old age pensions are illustrative answers to the biblical question, "Am I my brother's keeper?" With the present urge to procure a greater distribution of social justice, there is in some quarters a tendency to go to the extreme of com­plete socialization, in which effort medicine has been selected as a proving ground. If human intelligence and scientific medical knowledge could be dispensed in boxes and crates as a market com­modity, its distribution could be fitted into such a concept of eco­nomics. The fundamental concept in both ethics and economics is that of value. In economics the ultimate test of value is the amount of goods which will be consumed or the medium of exchange which will be. paid in the market. Ethics embraces a wider conception and makes it ultimate test of value the effect on the individual and the society in which he lives. If medical relations are to be ethical-that is, in furtherance of the ultimate good of the patient and of the public welfare-they must be between the patient who is to be treated and the physician trained according to established standards and having access to the accumulated knowledge of the ages. The advances in the distribution of medical knowledge during the past ftfty years have been evolutionary, developing means to meet the needs as they have arisen. The record is one of which to be proud; mortality has been reduced 50 per cent and life expectancy has been increased 100 per cent. During 1938 an all time low has been attained in the mortality of every disease other than heart disease and cancer. The explanation for their increased mortality becomes readily apparent when we bear in mind the number of people now living in the age groups above forty years, the period in which these diseases exact their greatest toll. •Address read by Dr. E. H. Cary, Dallas, In the enforced abeence of Dr. Abell, before the Qpeninir Exercises of the State :Medical Association of Texas, San Antonio, :May 9, 1989, and broadcast over Radio Station KTSA, San Antonio. Even with this remarkable accomplishment of American medicine, no agency knows better than the medical profession of the lag or gap that exists between accumulated medical knowledge and its equable distribution and no agency is more interested in bridging this gap, granting that it be done in a way to maintain the ethical institu­tion of medicine. As far back as 1875 the House of Delegates of the American Medical Association recommended the formation of a De­partment of Health with a cabinet officer at its head, to the end that all health activities might be coordinated and correlated. During the passing years it has repeatedly urged consideration of this pro­posal. During the same years there has been an increase in participa­tion of governmental agencies in health activities scattered through many departments, the Public Health Service in the Department of the Treasury, Maternal and Child Welfare in the Department of Labor, Food and Drugs in the Department of Agriculture, the care of the Indians and the insane in the Department of the Interior, the care of the Army and Navy in their own Departments, the care of the veterans in the Veterans' Bureau, the care of the indigent farmers in the Resettlement Administration, and so on through more than twenty different agencies involving the expenditure of many millions of dollars. The President of the United States appointed an Interdepartmental Committee to Coordinate the Health and Welfare activities of the Government, which in turn appointed technical committees to assist in the study of its problems, one of which devoted its activities to the study of medical care. The National Health Survey upon which some of its conclusions were based, was a spot survey made largely by WPA workers covering four million rural and urban inhabitants in seventeen states. By using the findings of this survey as an index to the needs of the country as a whole, the Technical Committee assembled data and reached conclusions that in many instances are at variance with the data and information collected by the American Medical Association. If it be true that one-third of the population is poorly clothed, poorly housed, poorly fed and with­out medical care, the problem presented thereby is even more social and economic than medical. The maternal death rate among the whites compares favorably with that of any other country, while that among the negroes is inordinately high. Many of the negroes live in squalor, are poorly clothed, poorly housed, undernourished and rachitic and without medical care even though it oftentimes is available; that such conditions exist is an indictment of society but certainly not of the medical profession. The availability of hospital service is another feature upon which there is a rather marked discrepancy. But regardless of its errors the report contains factual data upon which all agree and which form a basis for the consideration and study of all agencies in formu­lating a program for the wider distribution of medical care. In July, 1938, a National Health Conference was held in Wash­ington under the auspices of the Interdepartmental Committee, at which recommendations for a National Health Program were pro­posed, envisagin6r a comprehensive participation by the Federal Government in health activities. Briefiy, the program provided for an expansion of public health service and of maternal and child welfare; expansion and construction of hospital facilities and diag­nostic centers; medical care for the medically needy; aid to the state1 in developing plans for medical care on a tax-paid or com­pulsory insurance basis, and payments to the worker for disability resulting from sickness. The development of the proposed program was to be a gradual one with completion in ten years, at which time it would involve an expenditure of $850,000,000 annually. At a special meeting of the House of Delegates of the American Medical Association held in September, 1938, approval was given to expansion of public health service and maternal and child welfare where need could be shown; approval to hospital and diagnostic center construction where need could be shown, recommending, however, utilization of existing facilities to the utmost; approval of medical care to the indigent and medically indigent where need could be shown; approval of the principle of assistance to the worker for temporary disability resulting from illness; approval of group hospitalization and voluntary insurance but unqualified disapproval of tax-paid or compulsory sickness insurance. The special committee appointed by the House of Delegates held two conferences with the Interdepartmental Committee, one on Octo­ber 31, 1938, and one on January 15, 1939. Since the Interdepart­mental Committee did not at either conference submit a draft of the proposed legislative enactment for the translation of its recom­mendations into activity, the discussions were of necessity limited to principles. There was agreement in principle on the objectives of four of the recommendations but disagreement on Recommenda­tion IV which provides Federal help for the states initiating studies and plans for the care of all their people on a tax paid basis. Com­pulsory sickness insurance is a more appealing and euphonious title than the one which accurately identifies it, namely, sickness tax. Mr. Falk of the Technical Committee set the income level at which compulsory plans would operate at $3,000.00 or less. Federal statis­tics reveal that but 7 per cent of the population enjoy an income above this amount; if and when a compulsory plan becomes operative in all the states at this level, 93 per cent, or 120,000,000 of the population will be covered thereby. On January 2'3, 1939, the· President presented to the Congress his message on the National Health Program with a recommendation for its careful consideration and study. On February 28, Senator Wagner of New York, introduced into the Senate of the United States a bill, S. 1620, entitled "A Bill to provide for the general welfare by enabling the several states to make more adequate pro­vision for public health, prevention and control of disease, maternal and child health services, construction and maintenance of needed hospitals and health centers, care of the sick, disability insurance and training of personnel." Although the bill is actually an amend­ment to the Social Security Act, the bill proposes that if it is enacted it be called the "National Health Act of 1939." Assuming that this bill has the endorsement of the Federal agencies responsible for the National Health Program it has afforded opportunity to study the means by which it proposes to put into effect the recom­mendations of the Interdepartmental Committee and by comparison to see how far it harmonizes with the approval in principle given by the House of Delegates. at its special session. The American Medical Association at no time expressed its opinion upon the amounts of money to be expended in such a program but it is of interest to note that the Wagner Bill proposes an expenditure of $98,250,000 for the fiscal year of 1940, $123,500,000 for the fiscal year of 1941, and $334,000,000 for the fiscal year of 1942, with no limit in the amounts during 1941 and 1942 for public health work, for grants for mental and tuberculosis hospitals, for grants for medical care, for grants for temporary disability com­pensation and for administration; and, further, that for the fiscal years subsequent to 1942 there is no specified limit for expenditure for the accomplishment of any of the purposes of the Act. While no specific mention is made of compulsory sickness insurance, the measure introduces the principle of allotment of Federal money to the individual states for medical care, by the Social Security Board, without specifying the means to be used in the individual states for providing such service other than to demand the approval of the Social Security Board, being silent as to the permissible extensions and improvements of medical care that a State may make and as to whether such care shall be provided through a State medical service, or by a system of State health insurance, or by payment for services on a fee basis. The American Medical Association has at no time suggested an administrative agency for the National Health Program but has stressed its opinion that such be developed within State agencies and State medical bodies. The Wagner Bill specifies three admin­istrative agencies: the Children's Bureau, the United States Public Health Service, and the Social Security Board, with final full authority resting in each. The advisory councils mentioned in the bill are vague as to their membership, their duties and their responsibilities. Grant­ing the occurrence in a rural or isolated community of diseases, which from their classification would come under each and all three of these proposed agencies, satisfactory and competent adminis­tration would seem extremely difficult if not impossible. Such a contingency but enhances the contention of the American Medical Association for a Minister of Health, a unified agency for the corre­lation of all health activities. The bill does not provide for means of determining the local need for the various services it proposes to furnish, a matter of importance repeatedly emphasized by the House of Delegates. No stipulation is made as to the utilization and improve­ment of existing hospitals in the face of the fact that the hospitals of this country constantly show a 30 per cent bed vacancy. These are some of the points that demand our consideration and study in aiding in the development of a health program for the Nation, an intent to which we are by knowledge, experience, and conviction committed, its fundamental objectives being an expansion of public health, maternal and child welfare services, approved care to the indigent and medically indigent and an extension of hospital and diagnostic facilities. THE NEW DEAL AND THE SOCIALIZATION OF MEDICINE By W. B. RUSS, M.D. San Antonio, Texas (From Tezaa State Journal of Medicine, December, 1988, Vol. XXXIV, pp. 558-563.) The do-good dictatorship in Washington insists that it is the duty of the Federal Government, with or without the cooperation of the medical profession, to provide a new and better system for the dis­tribution of medical care to the poor. On July 18-20, 1938, a conference called by the Interdepartmental Committee to Coordinate Health and Welfare Activities of the Gov­ernment (organized under the Federal Security Act) met in Wash­ington. Miss Josephine Roche, representing the President, presided. One hundred and seventy-one delegates participated. A few repre­sentatives of organized medicine were present, and very much out of place. It seemed to be the consensus of opinion that the medical profession cannot be trusted to direct or control any plan having to do with the distribution of medical care. The C. I. 0. delegates dominated the discussion and were bitter in their denunciation of the doctors. Dr. F. C. Landrum, Director, Medical Research Institute, United Automobile Workers (a C. I. 0. organization) said "The American Medical Association is essentially a labor union of physicians built on craft lines for the purpose of protecting the economic interests of its members. It must be thought of as representing the few hundred doctors who have become wealthy in the practice of medicine." Eve Stone, Director of the Woman's Auxiliary of the United Automobile Workers (C. I. 0.) said, "Drastic change must come! The exclusive few in the medical profession who still attempt to hold back the wheels of progress and resist the social­ization of medicine will have to see that their continued opposition will not for long retard this development." Dr. Lewis T. Wright, representing the Association for the Ad­vancement of Colored People, had the following to say: "Any re­form should not be left in the hands of the Medical Profession (organized medicine) if the best interests of all American citizens of the lower income brackets are to be served." The Editor of The Nation observed that, "Owing to the obstructive and reactionary attitude of the American Medical Association, it seems unlikely that we shall ever be able to have successful plans for providing medical care in low and fixed fees." There were many speeches made by professional up-lifters, deplor­ing the fact that, partly due to greed and cruel neglect on the part o.f the doctors, there are forty million people in the United States unable to get medical care when they are sick. These speeches were all applauded with hysterical enthusiasm. The star of the occasion was Dr. Hugh Cabot, whose principal claim to fame rests in a dis­tinguished family name and the fact that he is from Boston. He ridiculed his own profession, denounced its leadership, and character­ized the practice of medicine in many parts of the country (meaning, of course, the South and the West) as medieval. The doctors were condemned as selfish, callous to the sufferings of the sick, arbitrary, and ignorant. The definition of "proper medical care" was left to the judgment of the theorists, who know nothing of the problem involved in treat­ing the sick. The absurd statement (based upon no reliable statistics whatever) that over one-third of the people in this country are denied adequate medical care was not even challenged by any except representatives of organized medicine. None of the schemes suggested made any clear line distinction be· tween the prevention of disease under the police power of the state on the one hand, and on the other, the treatment of the sick, which is a very different problem, and certainly one that the government cannot solve. The Washington Health Conference, like all New Deal activities, proposes to treat symptoms without taking the trouble to determine the cause of the symptoms. This is heresy to the medical profession. Doctors do not approve of treating symptoms without any reference to cause. Only miracle workers and quacks are guilty of that. Blessed by the President, dominated by the C. I. O. and all the Reds, pinks, and yellows, this so-called conference resolved itself into a grand rally in which the self-righteous fanatics proclaimed on behalf of themselves and the New Deal an absolute monopoly of all the human virtues, including honesty, justice, fairness, kindness, and sympathy for the poor. These emotionally drunk radicals, represent­ing the most dangerous communistic elements in society, had the effrontery to directly attack one of the two groups that have fur­nished the model for all social service organizations since the begin­ning of history. They completely ignored the fact that the medical profession and the church, through the hospitals, always have devoted themselves in body and soul to merciful administration to those who suffer from pain. They seem to have forgotten that long before even the horse and buggy days the fathers of medicine expressed the very essence of medical ethics when they denounced the thirst for gain and the desire for fame as the enemies of pity and the ministers of hate, prayed God to preserve their strength that they might be able to restore the strength of the rich and the poor, the good and the bad, the friend and the foe, and admonished the phy­sicians of their time and of all time to see in the sufferer the man alone. They seem convinced that the doctors and the church do not know and do not care that a large part of this nation is living in utter misery and semi-starvation. With the savage ingorance character­istic of scared poltroons, they demand that the care of the sick in body and in soul be taken from the medical profession and the church, and intrusted to the star-gazers, miracle workers, and utopia planners of the New Deal. Everyone knows of the poverty, ignorance, semi-starvation, and the scarcity of everything. Everyone knows that along with this poverty and misery there has been a complete moral and spiritual break-down, and everyone should know that when men are reduced to the level of the savage, unreasoning brute, mere creature com­forts or even efforts to prolong their lives will not save their souls. Their only chance for salvation is in the development of character, courage, and strength to meet the problems of an unkind environ­ment. The frightened, insecure, and unhappy victims of poverty, ignorance, and disease should not be encouraged to destroy their neighbors, and above all, they should not be organized to destroy all the spiritual values which have made America. Whatever schemes for relief are devised, whatever social planning is done, men of intelligence, experience and courage, who have demon­strated their fitness for leadership by successfully meeting their own problems, should be given the job. Fanatics and impractical people who have never done anything but make plans and indulge in day­dreaming, are not qualified for service at such a time. Above all, when the poor demoralized and ignorant man, woman, or child is faced with mystery and death, the family physician, counsellor, guide, friend, and neighbor must not be displaced or have a halter placed about his neck subject to the control of a New Deal bureaucrat or his meddlesome and troublemaking hirelings. No Washington bureaucrat can render service by interfering with the relationship between doctor and patient in the dark hours when the awful fear of death makes of the patient an unreasoning, frightened child. If the government is to distribute the taxpayer's money or to give any other aid to the sick poor, the distribution of that aid must be made under the control of the only social service organization that has stood the test of tim~the medical profession. The plan submitted to the conference provided for (1) expansion of public health service; (2) expansion of the hospital facilities and establishment of 500 or more health and diagnostic centers; (3) care of indigents; (4) Federal aid to states in the development of pro­grams for self-supporting persons burdened by unexpected illness; (5) insurance against wage loss during sickness The total cost of all the five proposals was estimated to be $2,600,000,000 per year. Everyone knows that the distribution of adequate medical care, particularly to self-supporting people of low income, presents a great problem that concerns both the doctor and the patient, but its solution certainly does not concern the impractical theorists who sought to control the health conference at Washington. Their efforts are far from helpful. Everyone faced with the terrifying experience of illness and pos­sible death, demands the very best medical care. If best medical care includes specialists, trained nurses and modern hospitals, then nothing less will be accepted as adequate medical care. The division of the practice of medicine into specialties that provide treatment as well as diagnosis, the high cost of technicians, trained nurses, hos­pitals, and other benefits of modern science, are responsible for the prohibitive cost of medical care. The contributions of modern science are responsible for the elim­ination of the traditional family physician or general practitioner, and for creating a false conception of what constitutes adequate medical care in the public mind. The idea that the function of the doctor and nurse is to assist the patient in making a fight against the disease, has been replaced by the modern notion that the battle is between the doctor and the disease, with the patient's part in the fight left out of the picture. In other words, the modern doctor is supposed to be able to cure disease instead of helping the patient to cure himself. This is in line with the philosophy of the New Deal, but violates common sense and experience of the human race. The replacement of the family physician and the neighborhood nurse by the modern specialist and the trained hospital nurse, aside from the cost involved has not been an unmixed blessing. For example in the matter of obstetrical practice, a few years ago the general practitioner, together with members of the family, provided adequate service to the pregnant woman, including prenatal care and care of the baby. The present-day obstetrical patient regards her gestation as a horrible and dangerous experience to be followed by c;:ertain mutilation and probable death at the end of nine months. Like any other frightened animal, she loses her ability to help her­self and, of course, always loses her milk. The fault is not with the modern science of obstetrics, but is due to loss of faith in the family physician and in the art of medicine. Many of the modern diseases like peptic ulcer and hypertensive heart disease are at least partly due to nervous tensions made worse by present-day methods of diagnosis and treatment. No one thinks that we can turn back the hand of ti.me and restore the horse and buggy doctor. Everyone knows that in the diagnosis of disease and the treatment of the patient, contributions of science must be employed. Everyone, however, seems to forget that if the patient must make the fight against the disease, the physician, not the patient or family or friend, must suggest and direct the treat­ment. The family physician, not the scientist who specializes in diagnosis and consultations, should have the care of the case. The government can reduce the cost of sickness and assure better services by providing free diagnostic centers in which are employed full-time, salaried specialists in all branches of medicine for diag­nosis and consultations, but without the privilege of treating the sick. Hospital care, also, could be provided by the government when needed. The American Medical Association recognizes and has always sup­ported, public health administration to protect the people from pre­ventable diseases. This service should be extended and all good citizens should cooperate with the government in the matter. In the treatment of the sick, however, the problem of the doctor is not confined to dealing with the disease that has the patient. He must also consider the patient that has the disease. Galen, one of the fathers of medicine, well said that no man who confines himself to the study of disease in the several parts of the body will ever be a good physician. The good physician must study the body as a whole with relation to its environment. Doctors do not cure disease. They merely help the patient to make the fight against disease. We are told by the planners that the slum people and the "Tobacco Road" share-croppers, are spreading disease because they are poorly housed, poorly fed, and poorly clothed. Housing, food, and clothing n1ay contribute to, but are not primarily responsible for, either the spreading of disease or any material increase in illness among the unfortunate. The trouble is ignorance, and lack of common sense. It is the ignorance of the "forgotten man" himself, not his housing and food that breeds disease, and, incidentally, causes the forgotten man to breed a progeny far too numerous for his own or his country's good. There are many poor people including Swedes, Norwegians, Danes, Germans, Czechs, English, Scotch, and Irish, in this country who do not spread disease. They are busily occupied with getting themselves out of the slums and out of the share-cropper class. They have sense enough to keep their bodies clean and not to eat filth. They have pride enough to want to improve their condition, and have courage and strength enough to make the fight. On the other hand, the dregs of foreign countries and the derelicts of this country, are in their present condition not because Henry Ford and his kind are successful, but because they lack the character and courage to dig themselves out of their sad plight. Out of the slums and the desolate rural areas will come many of the great men and women of the future, but they will come on their own power and not by the aid of the government--not by the redistribution of wealth, nor by changing the nature of or extending medical care. Their rise from poverty and misery will come through disciplined character, the overcoming of infantile habit patterns, from the primal urge in man to strive to struggle, to face danger bravely, to create-to be .something rather than to get something. After the Civil War, in the swamps of Louisiana, where I was born, some of the finest stock in America lived in shacks unfit to be called houses. They had the poorest and scantiest of food, and no clothing except what they could make themselves. They often had no medical care. Prenatal care, obsterics, and pediatrics, were usually left to some faithful colored woman, under the direction of Dr. Cabot's medieval country doctor, and yet the records show that neither the mothers nor the babies suffered from the high mortality and morbid­ity rates claimed for the share-croppers and slum-dwellers of today. The best and most intelligent survived. The shiftless and the ig­norant perished then as they do now. Thomas Mann points out that the nineteenth century generosity and sentimental kindness for the unfortunate have softened our character and is responsible for our present state of helplessness. Yet the emotionally drunk rabble-rousing, New Deal commissars, in utter disregard of the experience of the human race, are seeking salvation for the underprivileged by stressing their alleged rights, privileges, and prerogatives, instead of educating them concerning their duties, responsibilities, and obligations, by attention to which alone men can live in a world ruled by natural laws. Our New Deal leaders are teaching Americans to hold in contempt the things that have built what civilization we have. Everywhere we hear that the underprivileged biologically unfit :must be given social security and social justice, yet every man capable of thinking at all knows that the only social security possible is that due to character, courage, and the strength and power to live in the world as it is. Everyone must know that in the human animal, as in every other living thing, security depends entirely upon his ability to adjust himself to his environment. All that can be done for him through government is by the police protection that allows him an opportunity to compete on an equal basis with other living things. The law of change is always associated with a destruction of count­less billions of living forms. The law of change, like gravity, is beyond the control of any government, however benign its purpose. An individual's social security depends upon his character and his ability to live in a hard world. Social justice is exactly what the biologically unfit do not want. Social justice merely provides opportunities, not charity. Opportu­nity will not help a living thing which is unable to compete in a struggle in which nature has designed that very few, and only the best can survive. New Dealers seem to overlook the fact that human beings, like all living things, are under death sentence, the duration of the reprieve being conditioned upon the individual's behavior and upon circum­stances beyond the control of science. There seems to be no place in nature for useless things, and nature alone seems to be able to separate the fit from the unfit. No man, not even the President, can say who is fit to survive and who is not. The test of time and circumstance alone can determine that. The useful man seems to be willing and even anxious to die when he is convinced that his useful­ness is ended. When the strong and the brave man can no longer serve, life loses its charm. When the shadows of evening come, he is content to lie down like a tired child after a hard day's play. He welcomes with dignity and even a sense of relief, the dreamless sleep provided for all of God's great servants. On the other hand, the useless man, afraid of life and more afraid of death, seems to want tu live always. Man is supposed to have the advantage of intelligence, memory, and a social heritage, and therefore ought to profit by the experience of the race. The monkey, unable to profit by lessons of history, is a great social planner. Like the New Dealer, he plans often and always without regard to the experience and lessons of history. He plans a new world every morning. Unlike the New Dealer, however, the monkey does not organize the mob and get himself elected to office, for which we should be thankful. The unfit, the unfortunate, the weaklings, do not want justice; they do not want opportunity. They want charity. They have no sense of responsibility and duty; they have only rights and privileges­the right to live in a world too bard for them, and the privilege of living at the expense of their fellows, who, having a hard enough time on their own account, sometimes rebel, and become known to up-lifters as the selfish few. I have no sympathy for the self-pitying men and women who have turned their thinking against themselves under the guise of being kind. These fanatics want an easy world and easy tasks. They do not want to be strong men. They want tasks equal to their powers. not powers equal to their tasks. They are like the religious fanatics to whom heaven is a haven for the weak and the foolish. They are good, but only a New Dealer would know what they are good for. They are so certain that they are right that they will plan and execute any wrong thing on the theory that good in the end will come of their planning. They are so anxious to get to heaven that they will do anything, no matter how low down it is, to get there. They pity themselves and their kind, but they have a contempt for the hand that has been feeding them and keeping them alive. They despise the way of life that built America. The leaders of the New Deal, the rabble-rousers, who with joy plunder their .more fortunate neighbors are the quacks, the miracle workers, the makers of false promises. The leadership of the mob is like the leadership of any other stampede. The leaders of a stampede secure their leadership because they have the longest legs, the loudest voices, and are the most frightened of the herd. Our emotionally upset New Dealers get so confused that they think they are profound. They measure their depth by their dark­ness. They lack the foresight to see that when they have destroyed al! the wealth-producing power in the country and have crushed the spirit that made America, they will in turn destroy themselves and the pitiful mob they are leading to destruction. The intelligent leaders of organized labor surely have sympathy for and understanding of the problems of the poor, and yet the American Federation of Labor is already protesting against the New Deal plan of extending WPA aid only to those who can qualify as paupers. The jobless man who has been struggling and starving himself to save a pitiful equity in a life insurance policy or in a small home, or who in any other way demonstrates that he is willing to suffer and sacrifice rather than to accept charity, is discriminated against by the relief agencies which are reserved only for paupers in good standing-which means willing paupers. I am reminded of the Washington farm security expert who argued with the German farmer that since God had been so good in helping him to develop a fine farm and to keep out of debt, he should be thankful and help his neighbor. The farmer's reply that the expert should have seen that farm when God had it by himself, will forever disqualify him for a federal job. Liberty, opportunity, freedom from interference is all that any man can or should ask of any government. If this is provided and the man still lacks the intelligence, the courage, and the character to take advantage of his opportunity and his liberty and freedom from interference, then no government can do anything to help him. The problems of the machine age are great problems, and so were the problems faced by the colonists in conquering the wilderness. Adequate housing, food, clothing, and medical care, are problems, but our forefathers in the horse and buggy days had equal problems. They developed the disciplined character and the courage to get themselves out of their troubles without the advice or aid of govern­ment employees who are strong on theory and wasting the taxpayer's money, but short on ability to make a living for themselves. The "forgotten man" is a man who has forgotten himself, and who regards strong and successful men as cruel killers and economic royalists. He compares them to predatory animals. It is not the predatory animal, however, like the lion and tiger, that man has to fear, but the parasites, like lice, ticks, and fleas, that live on the predatory animals that are the destroyers. So it is with man. Society does not have to fear the strong and the brave. It is the biologically unfit, the spawn of dregs of foreign countries dumped on our shores, and the derelicts of our own country, that destroy society. For six years, in all the fireside chats, I have never heard the President say one word about the duties, obligations, and responsi­bilities of the forgotten man, not one word to indicate that the spiritual and moral pauper's plight might be due to something be­sides the competition of men who have taken the lead in making America rich and prosperous. I have never heard him suggest any­thing definite except that New Dealers who can be trusted to change their minds whenever he changes his, and submit to his dictation at all times, must be kept in control of Congress and the courts, on the theory that he and his unofficial advisers alone constitute the gov­ernment; and to denounce as traitors all who still insist that under the Constitution Congress and the Supreme Court are coordinate branches of the government, with the authority and the duty to func­tion as checks upon his power. Of course, only "princes of privi­lege" and the "selfish few" still believe in the Bill of Rights. The New Deal planners, like all quacks and miracle workers, offer a materialistic approach to the problem of living, a philosophy that destroys character and reduces man to the level of the lower animals. Housing, food, and shelter, may meet the needs of the pig and the cow, or even primitive man, but a man fit to live in a civilized world needs more than mere creature comforts. In this dark hour we need to find and treasure the things that have made America a great nation. It was not housing and food that made America strong. It was, instead, disciplined character, courage, ambition, the willingness to forget self, to sacr,fice, to suffer, and even to die rather than to surrender self-respect and become moral and spiritual paupers. The commissars in our benevolent dictatorship who place creature comforts above character and self-respect, should know that most of the men the world remembers and delights to honor, those to whom the monuments are built, whose names are enshrined in the pages of history, began life as forgotten men, without adequate housing, food, clothing, or medical care, and that not one of them was helped by social planners. If Columbus had consulted the social security planners of that day, he would not have crossed the ocean. If Lindbergh, Byrd, Hughes, and Corrigan, had given thought to security, or had placed regard for their lives and comfort above everything else in life, Europe and America would have been denied much inspiration. The men who made America had the courage to face danger. They were not afraid of life. They did not stand trembling in the presence of mystery and death. In them was a spirit of heroism, of adventure, the primal urge and drive that makes men climb the heights and plumb the depths-the urge to create, to achieve. Housing, food, clothing, and medical care, as means to salvation never have and never will suffice. Indeed, it does not profit a man if he gains the whole world and yet loses his own soul. To adopt the philosophy of the New Deal is to lose one's soul. THE CASE AGAINST STATE MEDICINE WINGATE M. JOHNSON (From Fortttn, Vol. XC, Nov., 1933, pp. 304-308.) The majority report of the Committee on the Costs of Medical Care, recently submitted after five years of preparation, was, in military language, a "dud." It is true that a few lay publications and a very few medical journals displayed a mild enthusiasm, but for the most part they either condemned or, worse still, ignored. There are a number of reasons for this lukewarm reception, although the report had been backed to the tune of a million dollars by eight "foundations," each financed by one or more "big business men." Their idea was to apply to the practice of medicine the methods of mass production which were once apparently elsewhere so successful; but by the time the committee had spent its money and issued its report, the big business man and his mass-production methods were alike so thoroughly discredited that no amount of ballyhoo could pump up any enthusiasm for their application to the ancient and honorable profession of medicine. One recommendation of the majority of the committee was that medicine be organized in smaller towns around hospitals as nuclei, supervised by superorganizations in the larger cities; but the chain­store idea did not appeal to a public holding numerous shares of Montgomery-Ward, Sears-Roebuck, and A. and P. stocks that were daily declining in value. And the recommendation "that the costs of medical care be placed on a group-payment basis, through the use of insurance, through the use of taxation, or through the use of both of these methods" did not appeal to a public already stag­gering under a load of taxes too heavy to bear. And when it later developed that some of the same "philanthropists" so interested in shifting the responsibility for the health of their employees to a paternal Government, rather than pay them decent wages, had themselves adroitly side-stepped their own taxes for a number of years, John Smith was still harder to interest in adding to the burden on his own back. Perhaps the chief result of the committee's report has been to focus attention more sharply than ever upon State medicine, which was virtually recommended by it. One member refused to sign the report because it did not specifically recommend State medicine to begin with; and in a recent Forum he presented a very clear and forceful argument for the faith that is in him. Theoretically, much may be said for it. Everybody would have the privilege of consulting, without thought of the cost, the physician of his choice. On the other hand, every doctor would be assured of a fixed income. All the financial burden would be distributed in taxes and paid according to the ability of the taxpayers. (Recent investigations might amend this last sentence to read "according to their skill in evading taxes.") II Now let us consider the arguments against State medicine. First, while its advocates draw a picture of the medical plight of the people that would draw iron tears down Pluto's cheek, the people themselves are not in such a bad way. Statistics are boring, but when the death rate in our own State has fallen from 12 per 1,000 in 1923 to 9.6 in 1932 and when the average life has been lengthened about 15 years within this century, it is hard to see how the people are so sadly neglected. It is quite true that this life-lengthening is in the early years rather than the latter; but it is also true that the strenuous pace which our big business men set for themselves and their employees has much to do with the degenerative diseases that beset the elderly among us. If such men would learn to content themselves with less profits and would pay their workers livin~ wages, both parties to the contract would benefit physically as well as spiritually. Pressing the point still further home, the committee's report laid great stress upon the fact that the income of the average family was too low to enable it to have adequate medical care; but instead of recommending a concerted effort to have wage scales raised, advised that the burden be shifted to the backs of the taxpayers. Furthermore, I question the accuracy of some of the premises from which the committee drew its conclusions. One study included a survey made by the Metropolitan Insurance Company with the obvious intention of making the cost of medical care for the average family appear as large as possible. In their study the first six months of 1929 were used, and the families under survey reported to the visiting nurse the amount of their medical expenses. The figures thus obtained were multiplied by two and used as an annual average. As a matter of fact, however, the Metropolitan's own statistics show that this period included the highest influenza incidence for the whole five years. The resulting figures were obtained by an enter­prising reporter for our daily paper, who applied them to our own county, stating under glaring headlines that the average income of the Forsyth County physician was considerably more than $12,000; whereas it is doubtful if a single physician in the county could boast that much. My secretary estimated that if the figures of the com­mittee held good, basing my income on the number of families on the active list and allowing a goodly share for the specialists, I was getting only a third of the amount due me. But let us consider the individual ease of the middle-class man or woman who is confronted with an emergency operation or illness and who has not the funds on hand with which to pay for it. No article advocating State medicine is complete without this case-report, in which the doctor is usually pictured as a sort of Shylock demand­ing his pound of financial flesh. Well, I know that if John Smith will tell his doctor frankly his circumstances and ask to be allowed to pay his bill in small installments, the doctor will gladly wait upon him. And I know, furthermore, that if John Smith has been depending for years upon one family doctor, who knows he pays according to his ability, that this doctor will not let him suffer for want of medical attention because of financial straits. Usually, too, the family doctor is apt to have influence enough with a surgeon or specialist to negotiate, if needed, an operation which can be paid for as convenient. My firm belief is that the average doctor will be far more lenient in dealing with John Smith than will the tax collector. State medicine would add so enormously to our tax burden that the groanings heard during the past few years would fade into insignificance beside the roars that would result from this added load. And does anyone think for a moment that with such a tre­mendous new source of revenue our politicians would keep their hands in their pockets? Not unless human nature changed over­night--and a rereading of the section on Democracy in Plato's Republic will convince the most skeptical that the political leopard has not changed his spots, in twenty-four centuries at least. Our educational system is frequently cited as a parallel case. Granting for the sake of argument that it is-how many Forum readers will concede its success? Certainly the article by Mr. James Metzenbaum in the June Forum on the school situation in Cleveland is not calculated to inspire confidence in the integrity of those who disburse the funds paid by taxpayers for education; and nobody believes that Cleveland is an isolated example. Those who want the taxpayers to assume the medical burden of the country should take warning from the rapidly mounting costs of our secondary school system. In 1880 the cost to the taxpayers was $5 per capita; in 1914, $21.34; now the annual cost is close to $100. Whether or not this is ever paid remains to be seen; but that we are failing to get our money's worth is certainly not to be debated. No less an author­ity than Ellery Sedgwick declares that "American education is a thing of trappings and appurtenances. Our schools are palaces and our colleges places to wonder at. But the teacher is not a leader, and the preeminence of the learned man is not unquestioned." Certainly the physician who values his self-respect would hate to undergo the humiliation the average teacher must feel in cringing before her principal, or the principal before the superintendent, or the superintendent before the august body of politicians known as the 8chool board. Yet if the physician's living depended upon pleas­ing a political superior, what else could be expected? Ill State medicine has already been tried in Europe. As is the case in most debatable questions, one may get opinions pro or con, accord­ing to the personal bias of the investigator or of the informer. This may account for the fact that most of the reports that have come to my ears and eyes have been unfavorable; but the fact that most of my information has been gleaned from medical journals which, in turn, have had their reports directly from doctors or from disinter­ested citizens, rather than from politicians and specialists in other people's business, should give it weight. A typical expression from a private physician is from Dr. Edwin Liek, of Danzig: "Social insur­ance is today organized to fill the feed trough of bureaucratic drones." Dr. Edward Ochsner, after a careful first-hand study of the situation, says, "Germany has had social insurance the longest and has for a considerable time been on the verge of bankruptcy. While other facts are operative, we believe that the billion dollars 196 The Univers'ity of Texas Publication which social insurance costs the nation every year is one of the chief reasons." Evidently the committee recognizes that the European experiments in the socialization of medicine has not been satisfactory, for it pro­poses to improve the situation by substituting group practice for individual doctors: "Many of the difficulties experienced ... under European systems will be avoided, the committee believes, if service is obtained from well-organized groups." Yet a survey just com­pleted by the American Medical Association indicates that group practice is meeting with much opposition, both within and without its own membership, and that its popularity is declining. It is, of course, wandering from our text to discuss group medicine, except for the committee's statement that if it be substituted as the medical unit, rather than the individual practitioner, it would do away with the objections to the European systems and make state medicine work in America. As I have said in a previous article, those who would substitute group practice for the individual doctor base their contention upon two great fallacies: first, that the average patient needs an exhaustive examination to find out what is the matter with him; secondly, that modern medical science can solve all disease problems. The first fallacy is exploded by the generally admitted fact that a competent general practitioner is capable of caring for from eighty to ninety per cent of the patients who consult doctors. The second fallacy is demonstrated almost daily in all our great clinics. Any doctor in the country can supply case histories in abundance. The group practice trend of the committee is understood when it is known that Mr. Edward A. Filene of Boston was largely respon­sible for its organization. Mr. Filene's ideas had already been set forth in a previous magazine article by Mr. Evans Clark, the director of his twentieth century fund. This article suggested that "possibly the most fruitful arrangement would be a group composed of two­thirds of doctors and one-third of experienced executives, with per­haps an economist or two thrown in." As a plain, blunt medical man, I cannot help wondering who would get the most fruit from such an arrangemen~the doctors or the "experienced executives." Evi­dently doctors must be considered on a low plane mentally if it takes one business man to manage the affairs of two doctors-not to mention "an economist or two" thrown in! And yet we are supposed to believe that such an arrangement would enable medical service to be dispensed more cheaply! Of course the number of "experienced executives" and "economists" available is much larger now than a few years ago-but what recommendations could they furnish? An inescapable conclusion is that the majority of those who advo­ cate state medicine, like the majority of the committee, do not regard the members of the medical profession as having sense enough to manage their own affairs. I am reminded of a doctor friend who, just out from an attack of influenza, was twitted by a banker for not knowing how to keep himself well. His patience already worn threadbare by frequent repetitions of this hoary joke, he replied: "If we doctors had made as big a mess of our job as you bankers have, I wouldn't have the nerve to criticize anybody else." Consid­ering the mess the big business men, some of whom are sponsoring the work of the committee, have allowed their own affairs to get into, it does seem in order for them to sweep up their own premises before giving their advice unasked to the profession that has suffered most grievously from the poor judgment of these same "experi­enced executives." Why should they be allowed to apply to the practice of medicine in America the same principles that have well nigh wrecked the medical structure of oth€r countries? As a brilliant medical editor said more than three years ago: "Ninety­five per cent of our population are better satisfied in their relations with their doctors than they are in their relations with their land­lords, their grocers, their clothiers, their preachers, or the teachers of their children." IV After all, the question of state medicine is bound up with the socialization of the state generally. With so many other pressing public needs, why should the medical profession be singled out for attack? Does not the public need fuel and clothing and food? And are not the costs of these subject to great fluctuations, just as is the cost of its medical care? Why not, then, let us join Russia in her "noble experiment" of communism, and be done with it? There a doctor gets twelve dollars a month for working six hours a day: some of them double and work twelve hours a day for $24 a month. Already our people have been spoon-fed by the hand of the govern­ment until they have lost much of their independence. A long step toward the complete loss of self-respect and manhood would be taken if they were still further pauperized by having free medical service forced upon them. It is almost impossible to overestimate the effect state medicine would have upon the doctor himself. It is recog11ized and admitted that some of the most brilliant discoveries and greatest medical triumphs have been achieved by medical men working for salaries in government laboratories or such semi-public institutions as the Rocke­feller Institute. It is true, however, that the research worker is altogether different from the practitioner. The researcher does better work for having his living provided for him, leaving him a free mind to apply to his laboratory. The practitioner, on the other hand, is an individualist by nature and by training. He learns to rely on himself, and is cramped if forced to take orders from higher author­ity. It is true that the stress of competition in private practice may develop heart-burning jealously between its .members; but it has also brought forth their best efforts. And a much higher incentive than that of competition is the trust imposed in him by his families. To merit their confidence, the right sort of doctor will make almost any sacrifice. Under state medicine, inevitably the old relation between doctor and patient would be destroyed. There could not be the same interest taken in his patients by a doctor working for the state as by one in private practice. In no other profession does the personal equation count for more than in medicine; and nothing would destroy this more quickly than state medicine, particularly if practiced by groups. SOCIALIZED MEDICINE IS IMPRACTICAL By WILLIAM ALLEN PUSEY, M.D. (From J&Unial of American Medical Insurance.) Medicine is, in fact, particularly exposed to the dangers of social­ization, because the projects of socialism that contain the first acceptance are those that have to do with health and physical welfare. There is an evident tendency now to appropriate medicine in the social movement; to make the treatment of the sick a function of society as a whole; to take it away from the individual's responsibili­ties and to transfer it to the state; to turn it over to organized movements. If this movement should prevail to its logical limits, medicine would cease to be a liberal profession and would degenerate into a guild of dependent employees .... In the next place, the machinery for all these socialistic and paternalistic enterprises will in time become so large and unwieldly that it will be impractical and fall to pieces. When, in addition to the ordinary machinery of government, we add the new machinery for running the mines and the railroads and the telegraph and the telephone and the wireless, for the regulation of capital and industry, for the stabilizatio11 of industry, for employment insurance and health insurance, for old age pensions, for socialized recreations and social­ ized neighborliness, for socialized health education and programs­ when on top of these you pile the organizations for keeping the people from using opium and cocain and alcohol and doing other things that are not good for them, for enforcing all sorts of laws that prohibit some of the population from doing things that another part thinks are wicked, for socialized nursing and medical care, for taking over obstetrics, child welfare and venereal diseases, for the care of the injured, crippled and defective-when these activities, nearly all of them temporarily good in themselves, have developed to a certain point, the burden will become too great. The men taken from pro­ductive occupation and private enterprise that will be required to man them will be such a large proportion of the population that, sooner or later, the social fabric will give way. There will not be enough of the population left for production to take care of the administrators; and a reaction, if not a crash, will come. In the next place, and most hopeful of all, society is usually saved from its own carelessness except when a cataclysm occurs-by the persistence of a minority element which, through character, intelli­gence and force, is able ultimately to exercise a controlling hand in the direction of affairs. If civilization is to be saved from the effects of a socialized mediocrity, it will be by the presence in the community of this influential minority..•. We hear so much n·ow about preventive medicine, about medicine's new social responsibilities, that this old responsibility is failing to stand out in proper proportions. Prevention is an important func­tion of medicine, and will doubtless become more so; but it is alto­gether likely that it will never be its chief function. Carry our dis­coveries to the utmost limit, man is still a machine that will get out of order, will be injured and will ultimately wear out. As long as that is true, there will be need for the personal physician to take care of the individual patient. For this service, thousands of physi­cians will be needed where hundreds can be usefully employed in research and preventive medicine. These are the men on the firing line; the battle for the relief of suffering depends on them. And the efforts of society, as of this Association, should be dedicated to the welfare, and development in training and character, of these men, engaged in the workaday duties of caring for the sick, wherever they are scattered over the face of the earth. To foster the competence of these men is the greatest social responsibility of medicine. COMPENSATION BENEFITS FOR THE SICK By SAME. THOMPSON, M.D., Kerrville, Texas The economic situation, the plans and recommendations facing the medical profession of this country today, suggest that we proceed cautiously and only after mature deliberation. Both our statements and our actions should be well thought out. The writer has the firm conviction that the medical profession of this country has more interest in and sympathy for the indigent and the helpless sick than all the social workers and uplifters combined. Since its beginning, the medical profession, at its own expense, met and honestly tried to solve the problems and burdens of the indigent sick. If those who are now loudly declaring their interest in and concern for the indigent sick were required to match what the doctors have given in the past, are now giving and will probably continue to give, their efforts would cease before the clarion voice of the crowing cock gives warning of the approaching dawn of another day. Our profession shares every humane impulse that urges better medical care of the indigent sick. The medical profession grants that in this and all other countries, we have the unfortunate indigent people who cannnot take adequate care of themselves-sick or well. We grant, with equal readiness, that when sick, they should have the soundest, safest medical care necessary to meet and solve--if possible-their problems brought about by illness and indigency. The complete indigent is one with no income and no resources. A relatively indigent is one who has an income, which if discreetly expended for food, shelter, and clothing does not leave enough for consistent medical care for himself and his dependents. The latter, economically, is a degree below those designated as the low income group. The completely indigent needs care and protection-sick or well­regardless of what brought about his indigency. He is helpless. The fine and sane thing to do would be to help him help himself. But you cannot help some people. You cannot cure the cause of all indigencies. Most of them are permanent. We have always had them. Unfortunately, we are now producing them. Indigency is at present more or less dignified and has a premium placed on it. It has been stated that the poor we shall have with us always. But that was before the new day with its social uplifters and multi­tudinous bureaucracies. The rampant sentiment in this country today is to do for people what they should voluntarily and pridefully do for themselves. And this is not limited to indigents. We are ignoring God's own law, that every man should be given talents according to his capacity to use and multiply them. But all of this does not solve the problem of compensation benefits for the indigents. The medical profession is ready now to take hold of an endeavor to meet this situation of properly and adequately serving the helpless sick. We will go along with any plan of medical service, which cannot reduce or destroy its efficiency. SOCIALIZED MEDICINE The most of this agitation over ways and means of caring for and bearing the burdens of the indigent sick has grown out of the report and recommendations of the National Health Conference. This report states that forty millions of our people are without adequate medical care when sick. This number is based on the committees' estimate that forty millions of the people in the United States earn or rather work for around $800 a year. In the opinion of the committee it therefore follows that this number cannot supply themselves with adequate medical service when sick. It is our belief that this is a misleading and unreliable con­clusion. We know the conclusion as to what each of the forty millions of people will do with $800 is wrong. Some of them will live well and save a little money. Some of them would not pay their honest debts if they received $3,000 per year. Because forty millions draw $800 a year, it does not follow that the entire number will be sick and suffer for lack of adequate medical service. Probably not more than five millions will be sick in any one year. We must not forget that the size of the man is of more importance than the size of the check. John D. Rockefeller began working for $4.50 a week and later gave away millions. Andrew Carnegie began working for $4.00 a week. Abraham Lincoln began working for $10 a month. When you give a small man a big check you create a larger problem than the ane we are attempting to solve. In discussing the economic situation in our country, we lose sight of the fact that you cannot standardize people. Lycurgus tried it during his reign and failed utterly. We talk about every man being entitled to the American standard of living, which would include safe medical service when sick. According to the laws of God and the previous laws of man, one is entitled only to what he deserves, what he earns. More than this must be charity. The National Health Conference recommended that the forty mil­lions designated be hospitalized and medically served when sick. The amount of money suggested for the first year to take care of this situation was more than eight hundred millions ( $800,000,000). As the years go by this was to be multiplied many times. If this report represents the true state of affairs-which we very much doubt--the doctors of this country stand ready to join hands with any force now existing or to be created, that we may take care of the sick man who cannot help himself. We know people, who when well, have no trouble in living up to respectable standards. They pay their debts and earn enough to meet every obligation of good citizenship. When serious and long drawn out illnesses come, they cannot meet them and pay their way. The welfare of this class, under this condition, is just as vital as the protection of indigency. In serving this class we are preserving something worth while--self-reliance. The same way to treat crime is to deal with the cause of crime. Very little is accomplished by treating the criminal. It does not solve the problem and as a rule does not lessen crime. If a dog has fleas on him, we should not kill the dog to get rid of the fleas. The treatment for the indigent--when he is sick-will not solve the problem. I doubt if it will lessen indigency. It merely makes indigency more pleasant and less distressing. If we could get at and intelligently deal with the cause of indigency, we might make some progress. We can never completely eliminate indigency. The best we can do is to reduce it. Another complication growing out of indigency is parasitism, which is worse than the original disease--indigency. Parasites-human parasites-which have been in the process of development in the last fifteen years more than ever before (it is now in the acute, pro­gressive destructive stage), have given us more trouble and cost more money than our problem of indigency. Parasitism yields definitely to the right kind of management. The best remedy for it is an empty stomach and permanent ventilations in that part of the trousers on which we sit. These, if let alone, will drive the parasite from his preempted economic state. The efficiency of socialized medicine is no longer a conjecture. In several countries it has been in service since 1918-twenty years. We know what socialized medicine has done and what it has failed to do. Twenty years is long enough to furnish reliable comparisons. On July 18, 1938, the National Health Conference reported or rather charged, that medical health services are bad in four spheres, as follows: 1. "Facilities for preventive medicine are wholly insufficient." The only informative way to consider this charge is to compare what has been accomplished in our country with what has been done in countries where socialized medicine is being practiced. In the ten-year period (1923 to 1933) diphtheria increased in Ger­many and in England while in the United States it decreased 65 per cent. In England, during that same period, tuberculosis was de­creased 28 per cent, while in our country where they claim medicine is lagging, tuberculosis was decreased 45 per cent. Germany and England are drifting along under socialized medicine. The Metro­politan Life Insurance Statistical Bulletin of January, 1938, gives us proof of America's medical superiority. A. "New all time lows for all causes of death." B. "New increase in the average life span to a new world record." C. "Death-Rate decrease of 36 per cent since 1911." D. "Highest life expectancy in the world for the American child." When socialized medicine equals or beats this record, we shall be glad to talk to them about changing our system. 2. "Hospitals are inadequate in many communities, especially in the rural districts; financial support is precarious." So far as I know, and I am fairly familiar with the hospital situa­tion-having owned one for more than twenty years-there are enough vacant beds in hospitals to accommodate any who might need the use of them. Many hospitals have been driven to group insurance to avoid financial sutfering from vacant beds. This does not sound like inadequacy. Empty beds have badly crippled or closed no small number of hospitals or the owners have wished they could close them without bankruptcy. With good roads and comfortable methods of transportation, access to hospitals is easy. 3. "More than one-third of our population, more than forty mil­lions, are without adequate medical attention." I do not believe it. am too much of a gentleman to accuse anybody of lying-but some­body has surely man-handled the truth. Just where these forty millions reside, I cannot find out. I have been looking for them ever since this report was published. I know they are not in Texas. I have talked with doctors in other states and they will not own them. The A.M.A. has written to the mayors of most large cities and they refused to confess them. It seems that Miss Roesche is the only person in the United States, who has been able to find them. In my opinion, the percentage is small-about like Mr. Volstead's beer in prohibition days--one-half of one per cent. 4. "More than one-third of the population suffers from economic burdens occasioned by illness." Somebody seems to think this is still 1932 and 1933-right in the middle of the depression; and there to stay. Brann used to say: "May God help the rich-the poor can beg." If it gets too hot we can still fall back on begging. Not long since I noticed that sixty-five billions six hundred and forty-eight millions of tax exempt securities were owned in this coun­try. The people in this country have more money on time deposit than in all other countries combined. We have more radios than any other country. There is one automobile to every four (4) people. There are enough cars to let every man, woman and child ride at one time and not have more than four (4) to the car. We spend more money vacationing than all other countries combined-and still we complain~specially through the National Health Conference and the Roesches. WE DECLARE WAR ON COMPULSORY SICKNESS INSURANCE AND SOCIALIZED MEDICINE-1935 By HOLMAN TAYLOR, M.D., Secretary, State Medical Association of Texas (From Teza.s State Journal of Medicine, March, 1935, :Editorial) The following editorial discussion is, in effect, a report of our dele­gates to a special session of the House of Delegates of the American Medical Association, called for the purpose of "consideration of the social and economic policies o fthe Association as related to pending and proposed legislation, to sickness insurance and to other matters which may be submitted by the Board of Trustees." The Texas delegation was as follows: Drs. J. W. Burns, S. E. Thompson, E. H. Cary, Holman Taylor and R. B. Anderson. It is not only desirable but essential, that the decision of our national law and policy-making body, in the present very serious and delicate situation, receive the thoughtful consideration and earnest support of the whole medical profession; either that, or its very prompt repudiation. This extraordinary meeting was held in Chicago, February 15-16. The attendance was 161 out of 175. Every section of our country was represented. It was truly a democratic gathering. The decision was unanimously in favor of resisting to the utmost all efforts to socialize medicine, and compulsory sickness insurance was condemned in terms most emphatic. Not only is it that there was no opposition to the final pronouncement of the House of Delegates, but by additional motion the decision was declared unanimous-this in order that it cannot subsequently be claimed that there was an inarticulate mi­nority. Evidently there was no minority. This fact is of the utmost significance. At the outset the Board of Trustees presented a complete and comprehensive account of the development of the predicament in which the medical profession now finds itself. This account is too voluminous to be reproduced here. It will probably be made available later on, either through the Bulletin of the American Medical Associa­tion, The Journal, or in reprint form. According to this statement of facts, sickness insurance was first a subject for discussion in the House of Delegates in 1916. At that meeting a committee was appointed to study the whole question of social insurance. An ef­fort was made at that time to educate the American medical profession in the general principles of social insurance. In 1917, the House of Delegates established the principle that in any legislation of this character freedom of choice of physicians should be insured; that the physician be paid in accordance with the amount of work done, and that the medical profession should be adequately represented in governing bodies. Each year until 1920, the House of Delegates reasserted its views in the premises, and in that year opposition was declared to any scheme embodying compulsory contributory insurance against illness or medical service to be rendered under the control or regulation of any state or the Federal Government. Since that time, it appears, many plans in many different communities have been tried, in an effort to do what is now sought to be done, insure ade­quate medical service at a satisfactory price and upon satisfactory terms. A commission was established to study these plans, and prog­ ress was made. The plans in operation in foreign countries were studied. Social workers, economists, and physicians were sent abroad for this purpose. These activities have been duly recounted in The Journal of the A. M. A., and other publications. Then came the now notorious Committee on the Cost of Medical Care, which operated under the influence of three philanthropic foundations primarily, the Twentieth Century Fund, the Milbank Fund, and the Rosenwald Fund. It will be recalled that the ma­jority report of this committee recommended a system of socialized medicine, with a strong minority report in opposition, and several lesser minority reports, one or two of which were communistic in character. In the meantime, the American Medical Association es­tablished its Bureau of Medical Economics, with adequate personnel. This bureau rapidly accumulated, compiled, correlated and made available all known facts and many fancies pertaining to sickness insurance. In 1934, the House of Delegates of the American Medical Associa­tion adopted ten fundamental principles for the guidance of the medical profession in the control of experiments with new forms of medical practice. At the same time the Judicial Council secured the adoption of amendments to the Principles of Medical Ethics, ex­pressing the recognition of the necessity for control of the practice of medicine by groups, hospital staffs, and in industry. It appeared at that time that the situation was well in hand and that, if left alone, the medical profession might readjust itself to changing condi­tions with that deliberation and poise so necessary in dealing with such highly personal and ethical matters. Then came the depression and the New Deal. This combination gave the socialist his day. The President of the United States sought to compose the situation and insure protection for the people. Immediately new ideas began to prevail, and with them the mirage of sickness insurance under the control of the government. Thus the Committee on Economic Security, including in its membership the Secretary of Labor, Frances Perkins; Secretary of the Treasury, Morgenthau; Secretary of Agriculture, Wallace; Attorney General Cummings, and Director of Relief, Harry Hopkins. This committee was expected to set up a new plan of taking care of the whole people. A technical advisory staff was established, with an executive director for each of thirteen divisions. Edgar Sydenstricker, an employee of the Milbank Fund, who presented a radical minority report for the Committee on the Cost of Medical Care, headed the medical service division. A medical advisory board was appointed, without reference to organized medicine, although one of its members was, and is, President of the American Medical Association. This committee has had small opportunity to advise concerning medical matters, and no authority whatsoever. The Director of the Bureau of Medical Eco­nomics of the American Medical Association, and one of his associates in the Bureau, were added to the technical staff. At the same time, Isadore Falk, a worker in the Milbank Fund, Michael M. Davis of the Rosenwald Fund, and Nathan Sinai, who had previously devised a plan of sickness insurance for the Michigan State Medical Society, were added to the staff. The Committee on Economic Security eventually offered to the President, who did not seem to be enthusiastically inclined to in­clude sickness insurance in the New Deal legislation, a series of eleven suggestions as to the possible development and application of sick­ness insurance. These suggestions were promptly submitted to the Congress in a message from the President. There then followed the so-called Wagner Bill for Social Insurance, introduced by Senator Wagner of New York, and covering old age assistance, unemploy­ment insurance, rehabilitation of crippled children, aid to dependent children, and the like. Under the predicate laid by national legis­lation of this sort, the various states might go ahead with their own ideas of social security legislation, including a renewal of the maternity benefit measure, heretofore known as the Sheppard­Towner law. In the meantime, it appears that those interested in a satisfactory (to them) distribution of medical service had organized the American Association for Social Security, with Abraham Epstein as executive secretary. This group has prepared a bill establishing a system of compulsory and voluntary state health insurance, to include prac­tically 95 per cent of the entire population of the United States. This bill is known as the Epstein Bill, and it is intended that it be introduced in all of the state legislatures as rapidly as possible. A critical analysis of this measure has been prepared by the Bureau of Medical Economics and the Bureau of Legal Medicine and Legis­lation of the American Medical Association. This analysis has been published in the Bulletin of the American Medical Association. In short, it was clearly shown that the American Medical Associa­tion has not been lacking in appreciation of the seriousness of the situation, or in leadership. Thus informed, the House of Delegates entered into a serious dis­cussion of the problem. Quite a few resolutions and suggestions were introduced and discussed. It seemed to be the consensus of opinion that there is not now and has not at any time been a real demand for a change in the present order of practice, either outside or inside of the medical profession, and that any plan of practice not wholly in keeping with the ten commandments of medical eco­nomics adopted at the Cleveland session of the American Medical Association last year would inevitably destroy all that is good and noble and genuinely useful in the practice of medicine. All of the suggestions made and the resolutions introduced, and the entire subject, were passed to a reference committee appointed for the purpose. This reference committee was of the highest order from the standpoint of personnel, and widely distributed in the matter of residence. The committee was headed by Dr. Harry H. Wilson of California. On the committee were Drs. Warren F. Draper of Virginia, E. F . Cody of Massachusetts, E. H. Cary of Texas, N. B. Van Etten of New York, F. S. Crockett of Indiana, and W. F. Braasch of Minnesota. This committee, after many hours of study, returned to the House of Delegates a well written report. The report was thoroughly discussed and returned for revision. The revised report as we have said, was adopted by unanimous vote. The report follows : "Your reference committee, believing that regimentation of the medical profession and lay control of medical practice will be fatal to medical progress and inevitably lower the quality of medical serv­ice now available to the American people, condemns unreservedly all propaganda, legislation or political manipulation leading to these ends. "Your reference committee has given careful consideration to the record by the Board of Trustees of the previous actions of this House of Delegates concerning sickness insurance and organized medical care and to the account of the measures taken by the Board of Trustees and the officials of the Association to present this point of view to the government and to the people. "The American Medical Association, embracing in its membership so.me 100,000 of the physicians of the United States, is by far the largest medical organization in this country. The House of Dele­gates would point out that the American Medical Association is the only medical organization open to all reputable physicians and estab­lished on truly democratic principles, and that this House of Dele­gates, as constituted, is the only body truly representative of the medical profession. "The House of Delegates commends the Board of Trustees and the officers of the Association for their efforts in presenting correctly, maintaining and promoting the policies and principles, heretofore established by this body. "The primary considerations of the physicians constituting the American Medical Association are the welfare of the people, the preservation of their health and their care in sickness, the advance­ment of medical science, the improvement of medical care, and the provision of adequate medical service to all the people These physi­cians are the only body in the United States qualified by experience and training to guide and suitably control plans for the provision of medical care. The fact that the quality of medical service to the people of the United States today is better than that of any other country in the world is evidence of the extent to which the American medical profession has fulfilled its obligations. "The House of Delegates of the American Medical Association re­affirms its opposition to all forms of compulsory sickness insurance whether administered by the Federal Government, the governments of the individual states or by any individual industry, community or similar body. It reaffirms, also, its encouragement to local medical organizations to establish plans for the provision of adequate medi­cal service for all of the people, adjusted to present economic con­ditions, by voluntary budgeting to meet the costs of illness. "The medical profession has given of its utmost to the American people, not only in this but in every previous emergency. It has never required compulsion but has always volunteered its services in anticipation of their need. "The Committee on Economic Security, appointed by the President of the United States, presented in a preliminary report to Congress on January 17 eleven principles which that Committee considered fundamental to a proposed plan of compulsory health insurance. The House of Delegates is glad to recognize that some of the funda­mental considerations for an adequate, reliable and safe medical service established by the medical profession through years of ex­perience in medical practice are found by the Committee to be essential to its own plans. "However, so many inconsistencies and incompatibilities are apparent in the report of the President's Committee on Economic Security thus far presented that many more facts and details are necessary for a proper consideration. "The House of Delegates recognizes the necessity under conditions of emergency for federal aid in meeting basic needs of the indigent; it. deprecates, however, any provision whereby federal subsidies for medical services are administered and controlled by a lay bureau. While the desirability of adequate medical service for crippled children and for the preservation of child and maternal health is beyond question, the House of Delegates deplores and protests those sections of the Wagner Bill which place in the Children's Bureau of the Department of Labor the responsibility for the administration of funds for these purposes. "The House of Delegates condemns as pernicious that section of the Wagner Bill which creates a social insurance board without specification of the character of its personnel to administer functions essentially medical in character and demanding technical knowledge not available to those without medical training. "The so-called Epstein Bill, proposed by the American Association for Social Security now being promoted with propaganda in the individual states, is a vicious, deceptive, dangerous and demoralizing measure. An analysis of this proposed law has been published by the American Medical Association. It introduces such hazardous principles as multiple taxation, inordinate costs, extravagant administration and an inevitable trend toward social and financial bankruptcy. "The committee has studied this matter from a broad standpoint, consider:ng many plans submitted by the Bureau of Medical Economics as well as those conveyed in resolutions from the floor o:C the House of Delegates. It reiterates the fact that there is no model plan which is a cure-all for the social ills any more than there is a panacea for the physical ills that affect mankind. There are now more than 150 plans for medical service undergoing study and trial in various communities in the United States. Your Bureau of Medical Economics has studied these plans and is now ready and willing to advise medical societies in the creation and operation of such plans. The plans developed by the Bureau of Medical Economics will serve the people of the community in the prevention of disease, the maintenance of health and with curative care in illness. They must at the same time meet apparent economic factors and protect the public welfare by safeguarding to the medical profession the functions of control of medical standards and the continued advancement of medical educational requirements. They must not destroy that initiative which is vital to the highest type of medical service. "In the establishment of all such plans, county medical societies must be guided by the ten fundamental principles adopted by this House of Delegates at the annual session in June, 1934. The House of Delegates would again emphasize particularly the necessity for separate provision for hospital facilities and the physician's services. Payment for medical service, whether by prepayment plans, install­ment purchase or so-called voluntary hospital insurance plans, must hold as absolutely distinct remuneration for hospital care on the one hand and the individual, personal, scientific ministrations of the physician on the other. "Your Reference Committee suggests that the Board of Trustees request the Bureau of Medical Economics to study further the plans now existing and such as may develop, with special reference to the way in which they meet the needs of their communities, to the costs of operation, to the quality of service rendered, the effects of such service on the medical profession, the applicability to rural, village, urban and industrial population, and to develop for presentation at the meeting of the American Medical Association in June model skeleton plans adapted to the needs of populations of various types." This report speaks for itself. Only that part of the report which refe'llS to the establishment by county medical societies of plans for the proper distribution of adequate medical service need be mentioned here. As a matter of fact in practically every community in the whole country, doctors have all along been furnishing adequate medical care for the people at a price and upon terms satisfactory to the public. It would seem necessary only to give this practice concrete form, through some plan which will meet local conditions, avoid abuses as far as possible and meet with the favor both of the medical profession and its dependent public. It probably matters little whether this plan involves a simple process of budgeting (which might be called insurance except for the many criticisms which have naturally come to that word), or a system of extension of credit and agreement as to price, in accordance with the financial circumstances of those who are served. It would seem that we have now adopted a positive rather than a negative policy with regard to sickness insurance and related prob­lems. As pointed out in the report, the Bureau of Medical Economics of the American Medical Association is now ready to advise with county medical societies in their efforts to develop plans for the delivery of medical service to their people. It should be remembered that in the development of any plan of distributing medical service, the ten commandments of medical economics must govern. It is perhaps wise to repeat them here. They follow: "1.-All features of medical service in any method of medical practice should be under the control of the medical profession. No other body or individual is legally or educationally equipped to exercise such control. "11.-No third party must be permitted to come between the patient and his physician in any medical relation. All responsibility for the character of medical service must be borne by the profession. "111.-Patients must have absolute freedom to choose a duly qualified doctor of medicine who will serve them from among all those qualified to practice and who are willing to give service. "IV.-The method of giving the service must retain a permanent, confidential relation between the patient and a 'family physician.' This relation must be the fundamental and dominating feature of any system. "V.-All medical phases of all institutions involved in the medical service should be under professional control, it being understood that hospital service and medical service should be considered separately. These institutions are but expansions of the equipment of the physician. He is the only one whom the laws of all nations recognize as competent to use them in the delivery of service. The medical profession alone can determine the adequacy and character of such institutions. Their value depends on their operation according to medical standards. "VI.-However the cost of medical service may be distributed, the immediate cost should be borne by the patient if able to pay at the time the service is rendered. "VIL-Medical service must have no connection with any cash benefits. "VIII.-Any form of medical service should include within its scope all qualified physicians of the locality covered by its operation who wish to give service under the conditions established. "IX.-Systems for the relief of low income classes should be limited strictly to those below the 'comfort level' standard of incomes. "X.-There should be no restrictions on treatment or prescribing not formulated and enforced by the organized medical profession." The above report of the Texas delegates, and the above quoted action of the House of Delegates of the American Medical Associa­tion, were unanimously approved, endorsed and adopted at a meet­ing of the Executive Council of the State Medical Association, February 24, 1935. This meeting was attended by 28 out of 31 members of the Council. PRINCIPLES OF MEDICAL ETHICS OF THE AMERICAN MEDjICAL ASSOCIATION-1937 ARTICLE VI.-COMPENSATION LIMITS OF GRATUITOUS SERVICE SECTION 1.-The poverty of a patient and the mutual professional obligation of physicians should command the gratuitous services of a physician. But endowed institutions and organizations for mutual benefit, or for accident, sickness and life insurance, or for analogous purposes, have no claim upon physicians for unremunerated services. CONTRACT PRACTICE SEC. 2.-It is unprofessional for a physician to dispose of his services under conditions that make it impossible to render adequate service to his patient or which interfere with reasonable competi­tion among the physicians of a community. To do this is detrimental to the public and to the individual physician, and lowers the dignity of the profession. By the term "contract practice" as applied to medicine is meant the carrying out of an agreement between a physician or a group of physicians, as principals or agents, and a corporation, organization or individual, to furnish partial or full medical services to a group or class of individuals for a definite sum or a fixed rate per capita. Contract practice per se is not unethical. However, certain features or conditions if present make a contract unethical, among which are: 1. When there is solicitation of patients, directly or indirectly. 2. When there is underbidding to secure the contraet. 3. When the compensation is inadequate to assure good medical service. 4. When there is interference with reasonable competition in a community. 5. When free choice of a physician is prevented. 6. When the con­ditions of employment make it impossible to render adequate service to the patients. 7. When the contract because of any of its pro­visions or practical results is contrary to sound public policy. Each contract should be considered on its own merits and in the light of surrounding conditions. Judgment should not be obscured by immediate, temporary or local results. The decision as to its ethical or unethical nature must be based on the ultimate effect for good or ill on the people as a whole. COMMISSIONS SEC. 3.-When a patient is referred by one physician to another for consultation or for treatment, whether the physician in charge accompanies the patient or not, it is unethical to give or to receive a commission by whatever term it may be called or under any guise or pretext whatsoever. DIRECT PROFIT TO LAY GROUPS SEC. 4.-It is unprofessional for a physician to dispose of his pro­fessional attainments or services to any lay body, organization, group or individual, by whatever name called, or however organized, under terms or conditions which permit a direct profit from the fees, salary or compensation received to accrue to the lay body or individual employing him. Such a procedure is beneath the dignity of profes­sional practice, is unfair competition with the profession at large, is harmful alike to the profession of medicine and the welfare of the people, and is against sound public policy. MEDICAL ECONOMICS By JOHN H. BURLESON, M.D. San Antonio, Texas (From Te11;aa State Journal of Medicine, March, 1936, Vol. 31, pp. 665-671) Before entering into a discussion of this subject, let me define "economics": It is the science that treats of the production and use of wealth. Medical economics if; the science of the distribution of medical service that will best conserve the financial interest of the patient and the doctor. This science can be adequately dealt with only by the medical profession. Medical economics has occupied the minds of many of the best men in the practice of medicine for quite some time. The problem is far from being solved. The profession generally has difficulty in separating Federal medical relief from medical economics. Many have failed to realize that medical economics is an insidious disease that is enveloping and destroying the ideals of our profession. When I began the practice of medicine, there were no economic problems; now we have a definite problem and one which we are going to solve or the practice of medicine will be taken over by the Federal Government. I wish to separate medical relief from medical economics. Medical relief should be classified as what the Federal Government has done to the doctor. Medical economics should be classified as what the doctors can do for themselves and their patients in spite of Federal interference. As President of the State Medical Association, I shall oppose any more agreements which include any combinations of the letters of the alphabet-be they N. R. A., P. W. A., or A. P. A. A burnt child dreads the fire; as a state profession we are out of it. Let us stay out. I have been asked to discuss medical economics from the standpoint of sickness insurance. Sickness insurance by those who have not given the subject serious consideration, would seem to be the solution of our problem. The more consideration given sickness insurance from the medical angle, the more convinced one becomes that it will not work. Several months ago, a committee was appointed by my home society to study the problem of sickness insurance. This committee, of which I was a member, was composed of fourteen members, the best that our society had to offer. After many meetings and serious consideration, the committee decided that sickness insurance was not the solution of our problem, and abandoned the idea. Immediately following the recent Atlantic City meeting of the American Medical Association, the report became prevalent that our great national body had endorsed sickness insurance. This received wide publicity in lay magazines, and was headlined in many im­portant newspapers. It is hardly necessary to say that the report was not true; it came quite naturally, if erroneously, from a mis­interpretation of a committee report, a part of which I quote: "An analysis shows that the class for which special provision is necessary is far smaller than most lay writers and so-called surveys would indicate. An investigation based up0n the resources of the individual, according to his ability to pay in graduated installments in most cases, meets the problem of the individual patient who is not wholly indigent. If the individual is indigent, he obviously cannot be expected to pay for medical services on an adjusted fee basis. In that instance, the medical cost is only one phase of the individual's economic distress. This problem requires more comprehensive measures than provision of medical service." In my opinion, sickness insurance is a good thing, and I hope the time is not far distant when old line insurance companies will write this character of policy, with the provision of absolute independence by the policyholder to select his own doctor and his own hospital; but under no condition should the medical profession have a financial interest in the set-up. To do so would destroy the altruistic attitude of the profession. Our business is to administer to the sick and to offer aid regardless of ability to pay; to be a partner in an insurance company would place us in the category of "money doctors." The point I wish to make is this: Medical economics must deal with the doctor's desire to take care of his people, and a way must be found whereby the profession can accomplish this end, and dis­sipate the idea propagandized by socialistic groups that the man of moderate means is unable to get medical attention. That medical care under modern conditions costs more than under the old order is granted. We also are thoroughly conversant with the fact that medical diagnosis is probably more exact than it was twenty or thirty years ago. I believe it behooves us all to take cognizance of and propagandize the laity with the fact that the best medical service today must cost more. Our equipment, methods of diagnosis, hospitalization-which formerly were not available-all contribute to the increased cost of medical care. We should stress in our daily contacts with our patients that good medical care does not necessarily mean expensive medical care. People should be educated to the fact that many diseases treated in hospitals may be handled successfully at home. While it is conceded that the public is entitled to adequate medical care, in no sense is the public entitled to the most expensive medical care; it is entitled to just what it can pay for, exactly as is the case of the purchase of any other com­modity. No one expects the poor to purchase the same expensive brand of flour, or cured meat, that the rich purchase. Neither would a poor man consider buying a Cadillac car. The rich and poor alike buy cars in accordance with their opportunities and desires, and abality to pay. Of course, every real sick person should have a trained nurse at the bedside all of the time, but can the public generally afford anything of the sort? I drove by a home this morning, in front of which there was a "quiet zone" sign, and on the front porch of that home were several persons who looked as if they hadn't had any sleep during the night. They were probably "sitting up" with the sick, who perhaps was not able to hire a trained nurse. In other words, those people are traveling in a used car, perhaps a Ford, and not in a Cadillac or Lincoln, as would doubtless be much more preferable. I am not an advocate of "tallow-candle medicine," but I do believe that many of us-and particularly the younger graduates in medicine, do not have the regard for our patient's pocketbook that we should. He demands hospitalization, laboratory work, and nursing. Much of this expense could be avoided by a little additional attention from the doctor; individual care would not only save the patient money but help to cement a personal relationship. We are losing the art of medicine; let any doctor, young or old, adopt this method of practice, of individual attention, and watch his practice grow. sometimes wonder if the passing of the family doctor is not the tragedy of the medicine of today.... The medical profession might be thought presumptuous for at­tempting to set up an economic system of its own. It might also be said that the doctor is notoriously a poor business man. Granting both premises, the physician is certainly in a better position to understand the economic problems involved in medical care than the economist without medical training or experience. I think this very circumstance responsible for the handling of medical cases under the Relief Act. I believe if the Congress had thought us capable of managing our own affairs we would have been given an opportunity to dispense the funds allotted to medical relief, and I think the medical profession should insist that it is able to handle medical relief without the interference of lay persons, that we are willing to do so and give accurate account of the money dispersed. Following this line of reasoning, the Government would get more for its money, the patient would get more and better treatment, and the medical pro­fission could render the service in a great deal better manner than under present conditions. It seems to me utterly impossible and im­practicable for a layman to assume that he can tell a doctor how to treat his patients. Medical relief is one of the greatest single factors in the rehabilita­tion of the indigent, and the doctor should not be handicapped with lay interference. The position taken, that medical relief is not basic, is absurd. Why give food to a person who is not well enough to eat? It is a reflection upon the intelligence, patriotism and honesty of the medical profession to assume that doctors are not capable of handling a fund set aside for this purpose, and turn the money over to people who have neither patience nor knowledge of our problem. As I have stated, the depression is only incidental; we must stabilize medicine so our people will be happy in their relationship to their doctors after the depression is no more. I am not one of those fatalists who think we are reaching the end of the world. Depression will pass and our country will be happy and prosperous again. When this happens, I want the medical profession to come forth with honor and respect. What has caused all this doubt that the profession is not able to handle the medical situation? The answer is ourselves. We have been propagandized on every conceivable socialistic idea pertaining to this whole subject. The chief offender against us is the "walli:ing delegate," commonly known as the social service worker. They are the persons who go into the community and organize mass examina­tions clinics for every conceivable ailment, and then when the scheme is ready to spring, they assemble the most prominent men and women of the community and convince them that it is the doctors' duty to correct the abuse, without regard for the injustice done the doctor. When the last analysis of the situation is reached, this walking delegate is the only person who is being paid. I would like to ask this pertinent question: What are the duties of a social service worker, and who are social service workers? Answering my own question, A social service worker is a person who has a college degree and a course of two years in a social service school, with training in or connection with a medical school or teaching hospital. My in­formation is there are about twenty such persons in Texas. Trained social service workers have a knowledge of psychology; they build up morale-not destroy it. Visiting the poor and sick with them is not a maudlin sentimentality but a scientific understanding of the problem. Their function is !educational; they have no ulterior motives, and work with the doctor and under his directions. There is no objection to properly trained social service workers; they really fill a place along with the doctor. My point is, they are not trained to foster the cause of socialism, and more especially medical socialism. The "walking delegates" to whom I refer are persons promoting relief in order to hold jobs. In my opinion they are destroying morale and doing more harm than good. They must make a showing, real or imaginary, and work upon the sentiments of the public in order to continue in business. In short, they are investigators, exploiting the public at the expense of the doctor. This is the kind of propa­ganda that has put us in the position in which we find ourselves. It is well known to all people that the doctors of a community do more for charity day by day, month by month, year by year, than the entire population put together. When Mr. Walking Delegate puts the proposition up to the doctor to render his services free, the doctor is brow-beaten and humiliated with the idea that if he does not lend his time and prestige to the proposition, his competitor will. The uplifters would do more good if they would confine their endeavors and energies to teaching people how to live, and stop mak­ing suggestions as to how medicine should be practiced. The Federal Government may regiment industry, but it is utterly impossible for any human agency to regiment brains and devotion to a principle, and that is all a doctor stands for.... My suggestion is that we interfere as little as possible with existing medical practice. I mean by this that there is no need to change our fee schedules, no need to change anything basic in our practices locally, such as the handling of compensation insurance or any con­tract that is recognized by State and National Associations. I believe that the practice of medicine should be divided into three classes: (1) Patients in the upper financial bracket, for whom nothing need be done. These people are well contented with the medical situation as it now exists. They are satisfied with their doctors, they are satisfied with their hospitals, and they are satisfied with present fees for medical service. This bracket represents about 20 per cent of our clientele. (2) The next bracket, which I will classify as patients in the comfort line, represents 60 per cent of our patients, .and, incidentally those from whom we make our living. This is the group that the up­lifter and the so-called social service worker hopes to make the public believe is being imposed upon. It should be kept constantly in mind that this up-lifter and so-called social service worker hopes and expects to get employment out of helping the medical profession practice medicine. This is where a part of medical expense already comes from. That it is getting increasingly harder for a man with a moderate income to pay his doctor and hospital bill, there is no ques­tion. The whole point in our dealing with medical economics must be around this man. After all is said and done, in cold critical analysis, the medical profession has not failed in the handling of the sick. Let us trace the origin of the free distribution of medical service. Looking back we find that the doctor himself started the custom of giving free medical attention to the indigent poor. They came to his office, asking for treatment, and said they were unable to pay. They were given attention and without charge. After a time, it became neces­sary for the doctor to set aside certain hours when he would receive this class of patients; this was necessary in order that he might have time to attend paying patients. Their numbers gradually increased to the point where the doctors found it necessary to segregate the sick in clinics. That was the foundation of the doctors' great problem of today. Hospitals were built around these free clinics and found support from public contribution. Staffs to man the hospitals were employed at salaries; only the doctor continued serving without compensation, and the custom of giving free medical service developed into an organized business. In this connection I would like to make this point, which all doctors know-once a free patient, always a free patient. The patient reasons that he was a fool ever to have paid a doctor when free treatment was available just around the corner. This is the crux of our present situation, free treatment of people because of economic depression; these people will never patronize their family doctors again. They have joined the nation's vast army of free treatment and to what size that army will grow no one can tell. There are one-half million people in this country being treated in free clinics every day. Assuming that the minimum charge is two dollars for each clinic visit, at this figure the doctors are donat­ing $1,000,000 daily to the sick who are, or pretend to be, so poverty­stricken that they must have free medical service. It is estimated that about 1 per cent of our populat\on is sick all of the time. Doctors daily treat 500,000 of these free-of-charge; after 500,000 nonpaying patients are attended, there are, based upon our popula­tion, 730,000 patients left who may be treated by private doctors and charged for services rendered. Records show that 35 per cent of the 730,000 patients do not pay their bills. If the remaining 65 per cent, or 474,000 patients, are divided among 142,000 family doctors, each would have an average of three patients per day. In the light of these figures, I would like to ask this practical question: Unless something is done by the medical profession, how can we survive? The number of persons attending free clinics has increased 300 per cent in the last ten years. To have medical attention without paying for it has become a national habit, I might say almost a national mania. It has even spread to the public schools ; from kindergarten to high school, pupils are instructed how to obtain free medical examination, and leave school with the fixed idea that the main­tenance of health and the correction of disease need involve little or no expense. (3) The third bracket, like the first, represents about 20 per cent of the practice of the physicians in any locality. I refer to the indigent, those whom the doctor has always taken care of for nothing. This is a situation that should be remedied. This dependent group are wards of State, County and Municipal governments, and should be taken care of by taxation. There is no more justice in requiring the doctor to take care of them than it would be to require the merchant to feed them, or the landlord to house them. We are our­selves to blame for this situation. The public should be definitely told that they are not our charge. These people should be taken care of in tax-free hospitals, and treated by doctors through the county medical society. If this is not possible, then city physicians and county physicians should be employed to take care of this dependent class. Medical relief as propagandized by socialistic agencies, and prac­ticed under "F. E. R. A.", appears to me to have been an attempt to pauperize our people from the standpoint of medical service, and was, so far as I can see, for no reason at all other than to make jobs for a horde of people who knew nothing about the care of the sick, and probably cared less. Medical service as thus set up, can never be satisfactory either to patient or doctor. Those in charge of this service in Texas ruled that medical attention is not a basic commodity. The State Medical Association committee having charge of our participation in this service, upon which committee I have served as a member for the past two years, definitely disagreed with this ruling, but to no avail. It would have been better, both for the patient and the doctor, had the matter of medical relief been turned over entirely to the State Medical Association. It is my feeling that any further service of this sort should be under the control of some such central medical organization. The medical profession can, and will, find ways and means of caring for its own people in whose families they have practiced throughout the years. SOCIALIZED MEDICINE By R. B. ANDERSON, M.D. Assistant-Secretary, State Medical Association of Texas In spite of all the talk about socialized medicine and the numerous articles on the subject in newspapers and magazines, to say nothing of medical journals, there seems to be a rather general lack of information as to what is meant by the term, and this confusion is not only in the minds of the public at large; lots of doctors want to krtow just what is meant by it. Not long ago, one of our most able speakers in the medical profession, a former president of our Association, who has made a great many talks over the State on the subject, wrote me and asked that I give him a concise definition of socialized medicine. I replied that I had never seen the term defined but I would write the Bureau of Medical Economics of the American Medical Association for a definition. I got a very prompt letter from him as a result with the admonition that "You and Holman Taylor (my esteemed chief) are supposed to be informed on all medical affairs, so get your heads together and crack down and give me a definition." With that order, there was nothing else to do, and the best that I had to offer was an adaptation from Webster's definition of socialism, "Socialized medicine may be said to be a method of medical practice controlled by the government to the end that, theore­tically, competition among medical practitioners shall give way to cooperation and opportunities and awards of practice shall be equitably apportioned among practitioners." At first, I was rather puffed up over my definition but when all is said and done, a much simpler one will suffice. Socialized medicine may be said to be col­lectivist medicine or medicine purchased on the group basis instead of by the individual. It is no secret that doctors generally are opposed to socialized medicine. Our reasons for that are not selfish; we are not thinking of ourselves alone but of the type of service that is rendered by independent practitioners and that rendered under socialistic forms oi practice. In order that we may learn from and not by experience, we must go to the countries which have socialized medicine and study how it operates there and whether it has proved satisfactory to the people in these countries, and whether the results are as satisfactory as we have in this country with our individualized system. The latter is what really counts. The best yardstick for both systems is the morbidity and mortality rates. Countries without socialized medicine, which includes the United States, have by far the lowest mortality and sickness rates, as compared with countries where socialized medicine prevails. A child born into the family of an average American wage earner has the highest life expectancy in the world. Contrasting the United States with Germany and Eng­land, which have forms of socialized medicine, we find that while diphtheria has increased in these two countries during the last ten years, it has decreased 65 per cent in the United States. In England, tuberculosis decreased 28 per cent over a ten year period, while in the United States it decreased 45 per cent. This same situation exists with the great majority of the disease conditions studied by the world's foremost statisticians. Why, then, would we want to substitute an inferior product for the finest medical service to be had in the world. Let use examine for a moment the types of socialized medicine in use elsewhere. First let me say that taxation is the source of revenue to pay for it, whether paid to the state or whether deducted from payrolls and called insurance. The medical profession is paid for its services by three different methods: first, by straight salary, as in Austria, which system is considered the most degrading and un­satisfactory; second, by a capitation fee, as in England, which is less objectionable, and third, for the act of service rendered, as in France, which, as far as the opinion of the medical profession is concerned, is the least objectionable of all. In France the patient goes to a doctor of his choice, and pays the doctor's fee himself for whatever medical service is rendered; he is given a receipt, which he takes to his insurance carrier, which, in turn, then pays the insured for 80 per cent of the fixed fee agreed upon by the system for that service. Only persons with an annual income of from $300 to $700 per year, or with one dependent child, $825, are entitled to services under the French system. The money to pay for the system is raised by a payroll tax of 3.47 per cent of the wages; it is pre­dicted that it will be necessary to increase this 1 per cent in 1939. To police the system and guard against abuses the government has in its employ a great number of doctors, who are constantly checking upon the diagnoses of the physicians chosen by the insured, it being estimated that about 50 to 75 per cent are being rechecked. This means a tremendous overhead and creates great dissatisfaction on the part of the people who are subjected to necessarily long periods of time waiting to be examined. The advantage of the French service is that the people do not run to their doctors for imaginary ills as under other services, because they have to pay personally and directly a part of the medical fee. Turning now to the system in England, which is frequently held up as a success by proponents of socialized medicine, we find that the service is paid for on a per capita fee, as stated before. In England, only those whose annual income does not exceed $1,250 are eligible for insurance medicine. This covers about 19,000,000 persons employed by industry. The 15,000,000 dependents of these insured are not covered by the system. England has a population of about 45,000,000. It should be said here that socialized medicine, wherever it exists is poor man's medicine; but it is not for the indi­gent; in no instance does compulsory sickness insurance do one thing for the indigent or pauper class, which is the only real problem of medical care in this country. Let us see how the service serves Jones, an English youth employed for the first time. His employer makes out an insurance card for him. His employer buys from the postoffice each week a stamp for 40 cents, which he affixes to the card. This stamp pays for Jones' insurance medicine and pension premiums, 18 cents being for the medical care. The employer de­ducts from Jones' wages each week 20 cents to pay for the stamp and he pays the other 20 cents. Thus, Jones pays about $9.36 per year for his insurance medicine. The next thing Jones does is to select his insurance carrier, which may be a trade union group, a commercial company or a state approved friendly society. His next task is to select a doctor. If he has none, one in his neighborhood is suggested, who is a part of the system. Less than half of the physicians of England are a part of the social insurance scheme. Jones takes a form to the doctor he has selected, the doctor tears off a part of the card for his own file, Jones keeps the remainder, and the doctor sends in another card to the insurance office, stating he has accepted Jones as a panel patient. Each panel doctor is permitted to have as many as 2,500 insurance patients, for each of whom he receives a per capita fee of $2.25 per year. On the face of it, this would look like a good income for a panel doctor, but if he had that many people on his panel he would require the services of an assistant. If the panel doctor chosen by Jones has a panel of 800 to 1,000, Jones will find, when he is sick, that he must be a patient patient when he calls on, or for his doctor. As a rule, office hours for panel patients are from 6 to 7 or 7:30 in the evening so that they may come and not interfere with their work. When Jones comes to see his doctor there will probably be twenty to thirty others there, all of whom the doctor must see in the hour or hour and a half. It is a typical dispensary practice similar but even more cursory than that used in the dispensary indigent clinics in this country. It has often been referred to as a "look and a bottle." The English people are famous for their avidity for medicine, and do they dish it out. In the mornings the doctor will have another office hour of from say 9 to 10, and either before or after that he makes house calls on panel patients. According to the size of the panel he may make from 20 to 50. It isn't necessary to say what type of service he can render each individual patient at this rate, regardless of his ability or conscientious desire to serve. The doctor's afternoon hours are given to his private patients, both for office and calls, many of whom may be dependents of his insured patients. Panel doctors do not follow their patients into the hospital. All serious conditions or at all puzzling or obscure condi­tions are promptly referred to hospitals and their responsibility ends there. A practice such as this cannot develop a physician's skill or diagnostic ability. With this brief reference to type of the most approved systems abroad, let me state briefly the defects of socialized medicine: 1. There is no decrease in the cost of medical care. The system adds a staggering administrative cost, with all the red tape required, bookkeeping, checks and counterchecks. 2. Public health and preventive medicine are not assisted or ad­vanced. Despite what proponents have to say, no system of socialized medicine has ever done anything to improve public health-and the United States leads the world today in its public health advances and advantages. 3. Overmedication is encouraged. Proponents of the system insist that what is needed in this country is to get people to doctors who in turn need patients. That is no doubt true but to get them in overwhelming numbers as in the English system, and demanding medicine which the hurried and overworked doctor dispenses or prescribes to get through, is not the best solution for the right type of medical care. 4. The burden of cost is distributed over the low income class, which is least able to bear it. Everywhere socialized medicine pre­vails it is made for the poor people, and there is a very definite income level. If it were extended, as has been proposed by exponents in this country, to the $3,000 annual income level, it would cover more than 95 per cent of the people and we would have the pre­posterous condition existing of a poor working man with less than 1,000 dollars a year income contributing to the medical care of people in the middle class group far more able to look after themselves. The disadvantages of compulsory insurance for medical care of the very poor is that you take from them funds they sorely need for other basic necessities, clothing, food and shelter, and thus indirectly contribute to a still lower standard of necessities which they may more sorely need more than medical care, which can be provided by other means. 5. Systems of socialized medicine make no provision for the in­digent, which is the greatest problem in this country. If a satis­factory solution were worked out for the medical care of the indigent, and doctors could be relieved of this burden, it would be very easy to provide medical service for the remainder of the population at prices they could afford to pay. 6. Graduate education is not encouraged by socialized medicine. Proponents of socialized medicine make much of this point, but ex­perience has proved that with an individual competitive system of medicine the United States leads the world in graduate medical education. 7. In socialized medicine the hospital load is increased. Insurance doctors are compelled to shunt off patients with obscure illnesses to hospitals because they do not have time to study them. As a result European hospitals are badly overcrowded and are all but collapsing under a financial burden they cannot carry. 8. Diagnosis and treatment are mechanical and superficial under socialized medicine, because under it doctors do not liave the time to study the individual patients and to make use of the wonderful advances medicine has made in the last several years. 9. And last, and most important, under socialized medicine, medi­cal service becomes a political issue, and its control is placed in the hands of unqualified nonmedical workers and organizations. Much is made of the fact by proponents of socialized medicine that in no country where it has been adopted, has there been a reversion to the independent, individual system. Sad to say, that is true. And if it ever is adopted in these United States we cannot expect any different experience. That should warn us against experimenting with it, as the proponents so glibly urge. Wherever it has been adopted there is developed a political bureaucracy, a multitude of new jobs for social workers, clerks, statisticians, and administrative help equal to or exceeding the number of physicians in the system­a political plum of the first magnitude. It was introduced by Bis­marck in Germany more than 50 years ago, and in England by Lloyd George in 1911, in each instance as political strategy. Once its talons are fastened upon the economic fabric of a nation, there is no way to loosen them. Turning now to this country, everyone knows of the more or less recent interest manifested in medical care, with emphasis on its cost, from the great number of articles that have appeared in news­papers and magazines. There have been several surveys on the subject in the last few years, instigated originally, no doubt, by those who were inspired by philanthropic motives. The findings of these surveys cannot always be accepted unequivocally, as the fact tinders included social workers and economists who may have been influenced by their prejudice for a system which would create many new jobs for their kind. American doctors know that all is not well with medical care in this country, despite the fact that people here in all walks of life receive better care than anywhere else in the world. And we are doing something about it, and I may add, are the only group that has continually worked on the problem from the beginning of our country until today, because that is our special sphere. We have about completed the most ambitious survey of medical care yet conducted, reaching into every hamlet, county and town of the United States. We are just as anxious, if not more so than any other group, to see to it that none shall suffer from lack of medical service, regard­less of color, race or creed. There are more than 250 plans in operation in different parts of the country, worked out by medical societies, to solve the problem of medical care for the low income group. More than 2,000 plans have been studied. We have worked out and approved hospital insurance, which goes far toward solving the problem of catastrophic illness. We have approved the principle of voluntary cash indemnity health insurance and plans of this sort have been worked out and are being tried out in different parts of the country. We recognize the need for spreading the burden of medical care for the indigent from the shoulders of the medical profession, where it has been borne magnificently for so long, and to let it rest partially, at least, on local communities, counties, the state, and, in some instances, the Federal Government. Referring to the National Health Program, we, and by we, I mean the medical profession, have approved in principle practically all its features, the only limitations being those we consider practical, such al:' the building of hospitals only where need exists. Our one com­plete disagreement with the program has to do with compulsory health insurance-and to that 110,000 American physicians through their national organization have objected unanimously. In spite of the fact that American medicine has not been dealt with so kindly by at least one arm of the Federal Government, our great national organization, some subsidiary bodies, and highly respected members now being under Federal indictment by the Department of Justice-­we have tried to cooperate and we are willing to play ball. We have given in on all points that we feel we can honorably do so, and not destroy the finest features in our system of American medical practice. I am reminded in this connection of the wife who got tired of her husband's proprietary attitude. She complained bitterly to him that she was eternally tired of hearing him say, "My house, my garden, my car, my son, etc."; that she wanted him to know that she had an equal interest in all these things and he should say, "Our house, our garden; our car, our son, etc." and she also wanted to know what he was doing in that closet to which he meekly replied, "Dear, I am just looking for our pants." Now this problem of medical care in the United States is as much your problem as it is ours. If you want to preserve the finest medical service rendered anywhere in the world, you had better be prepared to do something about it. WHO SHOULD PAY THE DOCTOR? THE PATIENT By MORRIS FISHBEIN, M.D. Editor, Journal, American Medical Association (From Rotarian Ma;ga;zine, Nov. 1936.) The practice of medicine began when the first ailing human being asked his neighbor or his relatives to help him out, and they tried to do something for his comfort. They did it with an understanding of the kind of man he happened to be, but without very much scientific knowledge of the nature of his body or the manner in which it worked. As human beings began to collect in cities, they soon found that a man's health might be a matter of considerable importance to his neighbor. Venereal diseases, it was discovered, were transmitted from one person to another. The failure to dispose of the excretions of the human body or of garbage led to illness of people in the vicinity. At this point, those who governed the community took action to make each person respect the rights of his neighbor. Thus the State became interested in medicine, at least in its public health aspects. Since that time public health has grown up as an individual profession, representing just a portion of medicine. There continue to be constant arguments and debates as to the extent to which the departments of public health shall enter into medical practice. We conceive it correct, for example, that the State, through its department of public health, shall control the water supply, the food supply, and the disposal of sewage, which are matters of vital in­terest to the health of the people. We conceive it to be in order for the State to determine when an infected individual is dangerous to the community and to limit his movements by isolation and quaran­tine. We recognize the right of the State in times when an epidemic of smallpox threatens to enforce the vaccination of individuals against smallpox. Does the State, however, have the right in times when no epidemic threatens to vaccinate individuals forcibly? Does it have the right, in the absence of diphtheria epidemic, to force children to be in­oculated by employees of the State against diphtheria with the use of diphtheria toxoid? Now diphtheria toxoid is well established as a preventive measure, whereas inoculation against whooping cough is still experimental; that is to say, presumably it does prevent whoop­ing cough in some cases, but not with the certainty that diphtheria toxoid prevents diphtheria. Does the State have the right to in­oculate any considerable number of children against whooping cough? From these questions it may be seen that there are different points of view as to how far the State may go even in the practice of p1·eventive medicine. It is a safe rule to observe that the State has the right to carry out any procedures which involve the health of the community as a whole, even when they concern the individual, but that the individual's personal health is his own affair as long as it does not too greatly concern the well-being of the community. Next comes the question of the treatment of disease. For years it has been the tradition in medicine that a patient shall have the right to select his own doctor and that the doctor shall be responsible to the patient for his care, and the patient responsible to the doctor for payment. In association with this practice has come the under­standing that doctors take care of those unable to pay, without any thought of payment, and that those able to pay shall do so according to their ability. As the number of indigents increased, particularly in large cities, institutions were developed where considerable num­bers of them might assemble as in dispensaries, or in hospitals, so that great numbers might receive medical care from a minimum num­ber of doctors. Yet these were not the only reasons for the growth of hospitals and dispensaries. A much more significant reason was the change that has occurred in the practice of medicine with advancements in scientific methods. For example, the doctor of 1875 depended largely on his five senses for the making of diagnoses, whereas the doctor of 1935 has every one of his senses improved and extended by thou­sands of new devices and materials. Thus medicine is practiced today not only by the doctors, but by a complete medical personnel. In the United States, alone, about 1,250,000 people give their full time to the care of the sick. More­over, instead of 1,000 hospitals for 90,000,000 people, as was the situation around 1900, we have today almost 7,000 hospitals for 125,­000,000 people. These hospitals are the workshops for the physician, provided for him in this country by state, local, or national govern­ments, by religious organizations, fraternal brotherhoods, corpora­tions, private organizations, and individual doctors. Many years ago, Bismarck in Germany established the idea that a good panacea for statesmen who found a considerable amount of unrest among the people was to offer the discontents cheap or free medical service. Out of this came the German compulsory sickness insurance system. When Lloyd George in England, around 1911, found the labor element likely to overwhelm the Liberal Party, he gave a compulsory sickness insurance system to the British people in the form of the Panel system under which they now receive their medical care. Many new demands have come upon the American purse during recent years; medicine has become more scientific and medical care much more competent. Naturally, the costs of medical care have correspondingly increased. As a result, people, have begun to query the medical costs. The economists are trying to ascertain whether or not some means may be found through better distribution of expenditures to provide more people with more complete medical service. From time to time, as these inquiries on rising medical fees have developed, various groups have given the subject their attention. For instance, a distinguished commission on medical education, after some seven years of study, came to the conclusion that about 85 or 90 per cent of the diseases for which people consult doctors can be competently diagnosed and treated by a general practitioner with the amount of equipment that he can carry in a handbag, or that he may happen to have available in his office. The remaining 10 or 15 per cent represent serious disease which requires study and treat­ment in a hospital. Incidentally, the records of the American Medical Association show that at least 100,000 of the 125,000 practicing doctors in the United States are associated with hospitals. The Commission found, more­over, that America has approximately 25 per cent more doctors than it ought to have, instead of too small a number, because the develop­ment of good roads, motor-cars, telephones, and hospitals makes it possible for one doctor to serve more people satisfactorily than was possible in former days. Another committee, known as the Committee on the Costs of Medical Care, composed largely of economists, labor and industrial leaders, social workers, statesmen, and doctors. studied the same sub­ject over a period of five years. Impressive to this group was the discovery that while once upon a time the gods of the American people were the professors, the philosophers, the preachers, and the doctors, today our prophets are the efficiency engineers. With the coming of the World War we learned how to organize vast numbers of people toward a single end. With the development of the Ford system of manufacture, the great department stores, and mail order houses, we learned how to manufacture and distribute material at a small cost through mass handling. Why then, said the efficiency engineers, can we not distr:bute units of medical service at a small cost through vast systems of organiza­tion? The answer, of course-and it must be a negative answer­lies in the inherent difference between the practice of medicine and the distribution of toothpaste and socks. Medical service is an individual service of one human being to another; its object is to relieve and to cure disease. No group, except the medical profession, is really entitled by training, by experience, 01· by law, to take care of sick people. All the features of medical service in any method of medical practice must, therefore, be under the control of the medical profession. If a third party comes between the doctor and his patient in any medical relationship, there enters an inevitable deterioration of the quality of service. A doctor em­ployed by an industry to take care of a sick worker obviously may feel his first responsibility is to his employer rather than to his patient, exactly as physicians employed by insurance companies have been known to protect the interests of the insurance company rather than the patient they were called to see. When a doctor knows that his reward depends on satisfaction of his patient, that patient is bound to receive the most that the doctor can give in his interest. The patient should have absolute freedom to choose a regularly qualified doctor of medicine to serve him from among all of those qualified to practice and willing to give him service. This will maintain the permanent confidential relationship between patient and family doctor which must be the fundamental and dominating feature of any workable system. Naturally we come next to the relationship of the hospital to the patient and to the doctor. The hospital looks for its payment to the patient, or to the corporaion, or to the insurance company which is paying for the patient. It is to the interest of the corporation or insurance company to get the patient out of the hospital as soon as possible, to the interest of the doctor to keep the patient in the hos­pital until he is assured that the patient is well and able to live, to the interest of the patient to stay in the hospital as long as is necessary for his recovery but not too long lest he lose his job and his position in the community. For these reasons, medicine has looked askance at schepies in which hospitals or corporations employ physicians to render medical service to patients, the patient paying the corporation and the corporation paying the doctor. Indeed, a fundamental principle states that all medical service of all hospitals or other institutions involved in medical care should be under professional control. Since the hospital is merely the doctor's workshop, no hospital is better than the doctors who work within its walls. Remove the doctor and you have left merely what would be a hotel with a certain amount of scientific equipment. Now it must not be thought from these statements that medicine objects to the organization of medical service for its improvement. There are, no doubt, certain procedures which may be carried on in mass relationship to the health of human beings which thereby will lower the cost of individual service. It do not refer to such intimate matters as child-birth, or even the removal of tonsils; neither do I consider the care of venereal disease a suitable subject for mass handling. On the other hand, the microscopic examination of speci­mens of blood and of urine, if carried out on a vast number of specimens at one time, lowers the cost of the individual examination. But remember, this involves a study of materials, not of live human beings. The mere fact that states have been able to take over education, road building, and sewage disposal is no warrant that any state can successfully take over the diagnosis and treatment of an individual disease. Those who know and understand the nature of medical care are inclined to believe that the last stand of the citizen in maintaining his status as an individual human being is going to be made when he is sick and too weak to stand at all. When a splinter of steel flies into a man's eye, when a shoulder begins to wear out with the lifting of heavy loads, or when a man takes into his body a large dose of germs with his drinking water, he begins to realize that there are parts of his body that have no realization of the state's desire to take care of him. These parts make their presence known in a disagreeable manner. Then, the citizen wants a doctor who will look at his eye not as an eye belonging to the State, but one belonging to John Smith. There is not today anywhere in the world socialized or State medical service that is complete; there is not one which has been satisfactory, because all of them are constantly being subjected to criticism and change. Even the most ardent advocates for socialized medicine for the United States, including Rexford Tugwell and William T. Foster, frankly admit that no system developed in other lands would be suitable for application to the American people; yet every plan proposed for application in America imitates in its es­sential setup some of the worst features of the foreign plans. In the typical setup recommended, the hospitals are to be the center of medical care. There hospitals are to employ a certain number of specialists and a certain number of general practitioners to take care of all of the people in the vicinity. It is presumed that patients will have opportunity to choose a doctor from the staff of the hos­pital to which they are assigned, or to which they may wish to go for treatment. The individual will find himself taxed a certain sum per year for his medical care whether he is sick or not, and the doctor will be paid either by the State or by the hospital for the service which he renders. His advancement, then, will depend on his popularity among the patients, or on political prestige. Anyone who has studied the American political system will realize, however, the great danger involved in making political prestige the term for preferment in giving medical service. In that play called MEN IN WHITE, Levine, a city doctor who has failed, says, "A doctor shouldn't have to worry about money. That's one disease he's not trained to fight. It either corrupts him­or its destroys him." And then he reflects: "Well, maybe some day the state will take over medicine." To this another doctor replies, "Before we let the state control medicine we'd have to put every politician on the operating table and cut out his acquisitive instincts." Today medicine throughout the United States is experimenting with new plans of organization to provide more and better medical care to more people at lower costs. Hundreds of plans have been developed whereby people voluntarily put aside a certain sum of money each month in order to pay the costs of hospital care should they need them. In New Orleans, for example, 30,000 people have voluntarily engaged in a hospital insurance plan which provides for free choice of doctor and hospital, and free determination by in­dividuals as to whether they care to engage in the plan. Innumerable county medical societies throughout the United States have aided in the development of prepayment plans for both medical care and hospital care. These plans vary. For example, a type of medical care suitable for a completely rural area like the large plantations of the South or of the wheat fields of the West. Actually, the medical profession is approaching the demand for new organization of medical practice in the same way that a good doctor approaches his patient first endeavoring to diagnose the con­dition and then, by the application of the available knowledge, to direct the treatment. It prefers, however, to use methods of treat­ment that have been tried on a small scale and found suitable, rather than to work out a new treatment for every case. It feels that experimentation under controlled conditions is the right system for maladjustments of social organization must as it is for disease within the human body. Even with these changes, however, the average citizen who wants for the future the same high quality of medical service that he has had in the past, but more of it and at a lower cost, must realize that medicine today is not the same as the medicine of 1875, and must learn to arrange his budget in relationship to his certain needs. In the development of new plans, the individual must remember that any plan which will take from him his individuality, particularly in times of illness, or any plan which will remove from him the personal consideration which is fundamental to the best type of medical care is a dangerous plan, regardless of the cost he may pay for the service. Until that time comes when human beings have been standardized, these mass plans for medical care are sure to lower the quality of medical service, and medical care can be judged only on the basis of the quality of service rendered. BIBLIOGRAPHY The amount of published material on socialized medicine in the United States is almost unlimited. The bibliography listed here is relatively brief. Magazine articles are omitted entirely. Anyone wishing an exhaustive bibliography including magazine articles may get it by writing to Library of Congress, Division of Bibliography, Washington, D.C., and asking for Medical Care in the United States and Foreign Countries with special reference to Socialization: Se­lected List of Recent Writings, compiled by Ann L. Baden, 1935, and Supplementary List to the above, 1938. I. ISSUES OF MAGAZINES DEVOTED TO ARTICLES ON BOTH SIDES OF THE QUESTION American Academy of Political and Social Science, The Medical Pro­fession and the Public: Currents and Counter Currents (1934), 112 p. (Articles by such men as Sydenstricker, Sigerist, Michael Davis, Parran, Fishbein, and Wm. T. Foster on both sides of the question.) Excellent. American Academy, 3457 Walnut St., Philadelphia. $1.00. Congressional Digest, "Should a System of Complete Medical Service Be Available to All citizens at Public Expense?" (Several pro and con articles and a short bibliography. Whole issue of maga­zine devoted to this question.) Excellent. Congressional Digest, August-September, 1935, v. 14, pp. 196-222. Congressional Digest, 2131 LeRoy Place, Washington, D.C., $1.00. The Inter­scholastic League, Box H, University Station, Austin, has a limited number of these pamphlets for distribution at 50 cents per copy. Stirvey Graphic, "Buying Health: a Special Number." December, 1934, issue. (Contains articles by W. T. Foster, Joseph Slavit, Edward A. Filene, C. E. A. Winslow, Michael M. Davis and others.) Excellent. Committee on Research in Medical Eco­nomics, 9 Rockefeller Plaza, New York City. Free. Or Pollak Foundation for Economic Research, Newton, Mass. (Pamphlet No. 105). 10 cents. II. DEBATE HANDBOOKS Aly, Bower, Ed., Socialized Medicine, the Debate Handbook, Vol. II, 1935-1936 (1935), 220 p. (Best reading material on both sides of the question and on medicine in general.) Excellent. Lucae Brothers, Columbia, Missouri. 80 cents. Buehler, E. C., Free Medical Care: Socialized Medicine (1935) 360 p. Excellent. Noble and Noble, 100 Fifth Avenue, New York City. $2.00. Heath, A. W., Tke Debaters' Workbook, State Medical Service (1935) 80 p. Waverly Forensic Press, Waverly, Ill. 75 cents. Johnson, Julia E., Socialization of Medicine, Reference Shelf, Vol. 10, No. 5 (1935) 335 p. Excellent; well worth the money. H. W. Wilson Co., 950 University Ave., New York City. 90 cents. Nichols, E. R., Socialized Medicine: Boston University, Affirmative vs. Bates College, Negative (1935) 35 p. (In Int,ercollegiate Debates (1935), v. 16, pp. 3-38). Noble and Noble, 100 Fifth Avenue, New York City. $2.50. Nichols, E. R., State Medical Aid: Debate Speeches at Michigan State College (1931) 44 p. (In Intercollegiate Debates, Vol. 12, pp. 205-49.) Noble and Noble, 100 Fifth Avenue, New York City. $2.50. Phelps, Edith M., Socialization of Medicine, Reference Shelf, Vol. VII, No. 1 (1930) 190 p. H. W. Wilson Co., 950 University Ave­nue, New York City. 90 cents. Quimby, Brooks, Medical Economics (1934) 32 p. (A good bibliog­raphy, and short briefs of arguments.) Pollak Foundation for Economic Research, Newton, Mass. 10 cents. Rankin, E. R., Socialization of Medicine (1935) 112 p. University of North Carolina, Extension Division, Chapel Hill, N.C. 50 cents. Socialized MecUcine: Kansas State College vs. Alabama Polytechnic Institute. Reprint from University Debaters' Annual, 1939-1934, pp. 376-408 (1935) 32 p. Good. H. W. Wilson Co., 950 Univer­sity Avenue, New York City. 35 cents. Walch, J. Weston, Complete Handbook on State Medicine (1935) 150 p. Debaters Information Bureau, 45A Free Street, Portland, Me. $2.50. III. GENERAL Bernheim, Bertram, Medicine at the Crossroads (1939) 250 p. Wm. Morrow and Co., 386 Fourth Avenue, New York City. $2.50. Bradbury, Samuel, Cost of Adequate Medical Care (1937) 86 p. Uni­versity of Chicago Press, Chicago. $1.00. Brown, Esther Lucile, Physicians and Medical Care (1937) 202 p. (Includes chapters on income of physicians, group practice, health insurance, and state medicine.) (Russell Sage Foundation, 130 E. Twenty-second St., New York City. 75 cents. Cabot, Hugh, Tke Doctor's Bill (1935) 313 p. (A splendid book; points toward health insurance.) Columbia University Press, New York City. $3.00. Christie, A.C., Economic Problems of Medicine (1935), 242 p. (The point of view of the private practitioner.) The Macmillan Co., 60 Fifth Ave., New York City. $2.00. Committee on the Costs of Medical Care, Medical Care for tke Amer­ican People: The Final Report of tke Committee (1932), 213 p. University of Chicago Press, Chicago. $1.50. Falk, I. S., Rorem, C. Rufus, and Ring, Martha D., Tke Costs of Medical Care; A Summary of Investigations on tke Economic Aspects of tke Prevention and Care of Illness (1933), 623 p. University of Chicago Press, Chicago. $4.00. Lee, R. I., and others, Tke Fundamentals of Good Medical Care: An Outline of the Fundamentals of Good Medical Care and An Esti­mate of tke Service Required to Suwly tke Medical Neetm of tke United States (1933), 302 p. University of Chicago Press, Chi­cago. $2.50. Leven, Maurice, Tke Incomes of Physicians (1932), 135 p. University of Chicago Press, Chicago. $2.00. Leven, Maurice, The Practice of Dentistry and tke Incomes of Den­tists in Twenty States: 1929 (1932), 224 p. University of Chi­cago Press, Chicago. $2.00. Newsholme, Arthur, Medicine and the State (1932), 300 p. Williams and Wilkins Co., Baltimore, Md. $3.50. Reed, Louis S., Midwives, Chiropodists, and Optometrists: Tkeir Place in Medical Care (1932), 85 p. University of Chicago Press, Chicago. $1.00. Riesman, David, Medicine in Modern Society (1938), 226 p. Prince­ton University Press, Princeton, N.J. $2.50. Rorem, C. Rufus, and Fischelis, Robert P., Tke Costs of Medicines (1932), 250 p. (Drugs and the service of pharmacy in the United States.) University of Chicago Press, Chicago. $2.50. Rorty, James, American Medicine Mobilizes (1939), 358 p. W. W. Norton, 70 Fifth Ave., New York City. $3.50. Salzman, J. A., Principles and Practice of Public Health Dentistry (1937), 584 p. The Stratford Co., 289 Congress St., Boston, Mass. $4.00. Sigerist, Henry Ernest, American Medicine (1934), 316 p. W. W. Norton & Co., 70 Fifth Ave., New York City. $4.00. Warbasse, James Peter, Tke Doctor and tke Public (1935), 572 p. (A study of the sociology, economics, ethics and philosophy of medicine.) Paul B. Hoeber, Harper and Bros., 49 E. Thirty-third St., New York City. $5.00. Wolf, George D., Tke Physician's Business (1938), 384 p. (Practical and economic aspects of medicine, especially ch. 14.) J. B. Lip­pincott Co., 227 S. Sixth St., Philadelphia, Pa. $5.00. IV. AFFIRMATIVE Baldwin, J. F., State Medicine: Its Imminence and Advantages (1932), 46 p. (An excellent presentation of arguments for state medi­cine.) Dr. Joseph Slavit, Chairman, American League for Public Medicine, 141 E. Nineteenth St., Brooklyn, N.Y. Free or at nominal cast. Davis, Michael M., Paying Your Sickness Bills (1933), 276 p. (Need for distribution of the costs of sickness by either taxation or insurance.) University of Chicago Press, Chicago. $2.50. Davis, Michael M., Public Medical Services (193'7), 170 p. (A survey of tax-supported medical care in the United States.) University of Chicago Press, Chicago. $1.50. Douglas, Fred J., SociaUzed Medicine. National House of Representa­tives, Jan. 24, 1938. Congressional Record, Seventy-fifth Con­gress, Third Session, v. 83, No. 18 (current file); 1375. Write your congressman for a copy. De Kruif, P. H. and R. B., Why Keep Them Alive? (1938), 293 p. (Preventive medicine.) Harcourt, Brace and Co., 383 Madison Ave., New York City. $1.49. Haines, Anna J., Health Work in Soviet Russia (1928), 177 p. Van­guard Press, 100 Fifth Avenue, New York City. 50 cents. Kallet, Arthur and Schlink, F. J., One Hundred Million Guinea Pigs (1936), 312 p. (Dangers in everyday foods, drugs, and cos­metics.) Grosset and Dunlap, 1140 Broadway, New York City. $1.00. Newsholme, Arthur, International Studies (The relation between the private and official practice of medicine, with special reference to disease prevention.) Vol. I. Netherlands, Germany, Denmark, Austria, Sweden and Norway. 248 p. $4.00. Vol. II. Belgium, Jugo-Slavia, France, Hungary, Italy, Czechoslovakia. 249 p. $4.00. Vol. III. England, Wales, Scotland, and Ireland. 558 p. $5.00. Williams and Wilkins, Mt. Royal and Guilford Avenues, Balti­more, Md. Newsholme, Arthur, and Kingsbury, John, Red Medicine: Socialized Health in Soviet Russia (1933), 324 p. Good. Doubleday, Doran and Co., 14 W. Forty-ninth St., New York City. $2.50. Reed, Louis S., The Ability to Pay for Medical Care (1933), 107 p. University of Chicago Press, Chicago. $2.00. Rogers, J. F., Student Health Services in Institutions of Higher Edu­cation (1937), 61 p. (U.S. Office of Education, Bulletin, 1937, No. 7.) U.S. Government Printing Office, Washington, D.C. 10 cents. Rorem, C. Rufus, Municipal Doctor System in Rural Saskatchewan (1931), 84 p. University of Chicago Press, Chicago, $1.00. Sigerist, H. E., Socialized Medicine in the Soviet Union (1937), 378 p. Excellent. W. W. Norton Company, 70 Fifth Ave., New York City. $3.50. V. NEGATIVE Carpenter, Niles, Medical Care for 15,000 Workers and Their Fam­ilies (1928), 96 p. (Endicott Johnson's workers' medical serv­ice.) University of Chicago Press, Chicago. 50 cents. Clark, Evans, How to Budget Health (1933), 328 p. (Guilds for doc­tors and patients. An exhaustive treatment of practices and possibilities in group and insurance medicine.) Harper and Bros., 49 East Thirty-third St., New York City. $4.00. Crownhart, J. G., Sickness Insurance in Europe (1938), 134 p. (Strongly critical.) Published by J. G. Crownhart, Secretary, State Medical Society, Madison, Wisconsin. Falk, Isidore S., Formulating an American Plan for Health Insurance (1934), 8 p. American Association for Labor Legislation, 131 E. Twenty-third St., New York City. 10 cents. Falk, I. S., Security Against Sickness (1936), 423 p. (A study of health insurance.) Doubleday Doran & Co., 14 W. Forty-ninth St., New York City. $4.00. Fisher, Percy C., An Argument Against the Socialization of Medicine, National House of Representatives, Jan. 5, 1938. Congressional Record, Seventy-fifth Congress, Third Session, V. 83, No. 3 (cur­rent file); 108-110. Write your congressman for a copy. Ochsner, Edward H., Social Security (1936), 231 p. (A strongly critical analysis of health and social insurance by an M.D.) Social Security Press, 538 S. Wells St., Chicago. 50 cents. Orr, Douglas W., Health Insurance with Medical Care: The British Experience (1939). Macmillan Co., 60 Fifth Ave., New York City. $2.50. Reed, Louis S., Health Insurance, The Next Step in Social Security (1937), 281 p. Harper and Bros., 49 East Thirty-third St., New York City. $3.00. Rorem, C. Rufus, Hospital Care Insurance (1937), 71 p. (The periodic payment plan.) American Hospital Association, 18 E. Division St., Chicago. 50 cents. Rorem, C. Rufus, Private Group Clinics (1931), 130 p. (Adminis­trative and economic aspects of group medical practice.) Uni­versity of Chicago Press, Chicago. 75 cents. Shadid, Michael A., A Doctor for the People (1939), 277 p. (Auto­biography of the founder of America's first cooperative hospital at Elk City, Oklahoma.) Vanguard Press, 424 Madison Ave., New York City. $2.50. Shadid, Michael A., Principles of Cooperative Medicine. Publisher: Michael Shadid, Elk City, Okla. 50 cents. Simons, A. M. and Sinai, Nathan B., The Way of Health Insurance (1931), 300 p. University of Chicago Press, Chicago. $2.00. Warbasse, James Peter, Cooperative Medicine: the Cooperative Or­ganization of Health Protection (1936), 24 p. Cooperative League, 167 W. Twelfth St., New York City. 15 cents. Williams, Pierce, and Chamberlain, Isabel, The Purchase of Medical Care Through Fixed Periodic Payment (1932), 308 p. National Bureau of Economic Research, 1819 Broadway, New York City. $3.00. VI. PAMPHLETS, AFFIRMATIVE AND NEGATIVE American Hospital Association, 18 East Division Street, Chicago, Ill. All items Free. 1. The Influence of Hospital Care Insurance Plans Upon Med­ical and Hospital Service (April, 1938), by C. Rufus Rorem. 2. Directory Indicating Membership or Enrollment in Non­Profit Hospital Service Plans as of April 1, 1939. 3. Standards for Non-Profit Hospital Care Insurance Plans (Jan., 1938). 4. Voluntary Hospital Care Insurance (Reprinted from State Government, May, 1939), by C. Rufus Rorem. American League for Public Medicine. Write to Dr. Joseph Slavit, Chairman, American League for Public Medicine, 141 E. Nine­teenth St., Brooklyn, New York. All items free or at nominal cost. (Write for a list of material which they have available.) American Medical Association, Bureau of Medical Economics, 535 North Dearborn Street, Chicago, Ill. 1. America's Town Meeting of the Air, Debate by Michael M. Davis and Morris Fishbein on Health Security and the American Public. Published by American Book Co., 88 Lexington Ave., New York City. 10 cents (1936). 2. Care of the Indigent Sick; Including a Description of State Plans Under the Federal Emergency Relief Administration (1936), 123 p. 50 cents. 3. Cooperatives and Medical Service (1937), 10 p. Small charge. 4. Economics and Ethics of Medicine (1936), 69 p. 15 cents. 5. Group Hospitalization (1937), 296 p. 75 cents. 6. Handbook of Sickness Insurance, State Medicine, and the Cost of Medical Care (1935), 182 p. 40 -cents. 7. Health Insurance in England (1938), 29 p. Small charge. 8. Introduction to Medical Economics (1935), 108 p. 25 cents. 9. New Forms of Medical Practice (1939), 64 p. 10. Radio Debate on State Medicine: Affirmative, W. T. Foster and Bower Aly; Negative, Dr. Morris Fishbein and Dr. R. G. Leland. Excellent. Small charge. 11. Rural Medical Service, 80 p. Small charge. 12. University and College Student Health Services: A Report (1936), 187 p. $1.00. Committee on Research in Medical Economics, 9 Rockefeller Plaza, New York City. All items Free. 1. The Ability to Pay for Medical Care, 15 p. (An Abstract of the book by the same title by Louis S. Reed, cited under Affirmative.) 2. The American Approach to Health Insurance, by Michael M. Davis. 15 p. 3. The Case of the Ross-Loos Clinic, by Mary Ross. 6 p. 4. Case Stories About the Costs of Medical Care and the Ability of People to Pay. 23 p. (Very interesting.) 5. The Economic Aspects of Medical Services. 51 p. (Taken from the book entitled Costs of Medical Care, by Falk, Rorem, and Ring, listed in bibliography [general].) 6. Health Security and the American Public, by Michael M. Davis. 18 p. 7. The Incomes of Physicians, 11 p. (An abstract of the book by the same title by Maurice Leven, cited under General.) 8. Institutional Convalescence, by E. H. Lewinski Corwin. 8 p. 9. Julius Rosenwald Fund: Eight Years' Work in Medical Economics, 1929-1936; Recent Trends and Next Moves in Medical Care (1937), 45 p. 10. The Physician's Profession Through the Ages, by Henry E. Sigerist, Johns Hopkins University (1933). 15 p. 11. Private Group Medical Service; the Economic and Profes­sional Aspects of a Private Clinic in a Mid-Western City, by C. Rufus Rorem, PH.D., and John H. Musser, M.D. 12. Sickness Bills by Installment, by Mary Ross, Reprinted from Survey Graphic (1935). 13. Sickness Insurance and Medical Care, by Michael M. Davis (1934), 19 p. 14. Survey Graphic, December, 1934. Buying Health, A Spe~ial Number containing Health Articles by many outstanding writers. Forty-five large pages. Cited above as Issue of Magazine Devoted to Health Articles. Excellent. Pollak Foundation for Economic Research, Newton, Mass. (All items ten cents each; order pamphlets by number, and in every case send check or postage stamps with order.) 102. The Layman's View About the Costs of Medical Care. 103. Picture Book About the Costs of Medical Care, Revised Edi­ tion, 1937 (Reproduced in this bulletin). 105. Buying Health (December, 1934, issue of the Survey Graphic). 107. American Approach to Health Insurance, Michael M. Davis. 108. Incomes of Physicians (Abstract of book with same title by Maurice Leven). 110. A Survey of the Medical Facilities of the State of Vermont. 111. A Survey of the Medical Facilities of Shelby County, Indiana. 114. Fundamental Facts on the Costs of Medical Care, I. S. Falk. 115. The Physician's Profession Through the Ages, Henry Sigerist. 116. Group Payment for Medical Care, Stancola Plan, C. Rufus Ro rem. 118. Sickness Insurance and Medical Care, Michael M. Davis. 28. Handbook for Debaters on Medical Economics, by Brooks Quimby, Revised Edition, 1935, 32 p. (Cited above under Handbooks.) 121. What It Is All About, by William Trufant Foster; and Achievements of the Medical Profession, by Walter P. Bowers. 122. Uncared-For Needs, C. E. A. Winslow. 123. Group Payment for Hospital Care, Robert Jolly. 124. Public Health Needs, Thomas Parran, Jr. 125. Preventive Medicine, George H. Bigelow. 126. Mass Prosperity and Medical Care, Edward A. Filene. 127. The Doctor's Part in Medical Care, Ray Lyman Wilbur. 128. Uneven Costs of Sickness: How to Meet Them, Paul H. Douglas. 129. Progress in 1934, Michael M. Davis and C. Rufus Rorem. 130. Budgeting Hospital Bills, Frank van Dyk and Homer Wickenden. 131. The Nurse's Part in Public Health, Miss Katherine Tucker. 132. Mutual Health Service, Nathan Sinai. 133. The Government's Part in Medical Care, William Hard. 134. Where Doctors are Lacking and Why, Haven Emerson. 135. Present Trends in Health Insurance, I. S. Falk and Edgar Sydenstricker. 136. The Man from Mars Asks Questions, Harry H. Moore. 137. Next Steps, Livingston Farrand. 138. Medical Care for All, Arthur Newsholme. State Medical Association of Texas, 1404 W. El Paso Street, Fort Worth, Texas. The Association operates a package loan library, but is not equipped to send packages to places all over the state; however, a letter to them might result in a lead to other material not now available. The Dallas Civic Federation, 2419 Maple A venue, Dallas, Texas. The Civic Federation has some material which should be avail­able to debaters in and around Dallas.