Of early mature life the great scourge is, of course, tuberculosis. The principles of the world-wide campaign against this leading cause of death are far too familiar to need recapitulation. It is in all ways a health campaign. Its gospel of pure air and sunlight, plain and substantial food, cleanliness, abstinence from the use of stimulants, early diag nosis, and rest from injurious occupation, has cer tainly been one of the chief elements in the general sanitary progress of the past two decades. The enthusiasm which the anti-tuberculosis campaign has aroused is no doubt largely due to this fact, that nearly all its features of which the lay public takes account are equally features of almost any health campaign. Consumptives should not live in damp basements or in dark interior rooms. But who should? Consumptives must have plenty of milk and eggs. But for whom are those delicious ar ticles of diet not appropriate? Consumptives must be helped to get out of dusty trades, overheated shops, work requiring a stooping, chest contracting posture. But for whom then of the children of men are such conditions beneficial? Consumptives should not spit promiscuously, for reasons often carefully explained. But is any other desiccated, pulverized sputum a welcome addition to the air we breathe? Consumptives should be cleanly, conscientious in not endangering the lives of others. Are those not universally desirable virtues? Al coholism is a dangerous complication in tubercu losis, but it is also a dangerous complication in life.
This is not to suggest that there is no differentia tion, from the medical point of view, in the specific treatment of tuberculosis and other diseases. Of course there is, and one of the valuable features of the tuberculosis campaign is its insistence upon sanatoria, clinics, laboratories, and other special ized equipment both for research and for relief on lines already fully established.
Typhoid, pneumonia, malaria, rheumatism, colds, and headaches all interfere with normal life in the home, as, of course, also with incomes and efficiency at work. Elementary policies of social construc tion demand consideration of each, to examine how they may best be controlled, how their economic and social effects may be reduced to a minimum and most judiciously distributed. They are not pri vate, personal matters, but social phenomena. No man has a right to have a headache even, if society can prevent it, much less typhoid, pneumonia, a cold, or any other communicable disease. The rights of others are involved in so many ways that the most unsocialized egoist must recognize that his diseases are affected, as the lawyers say, by a public interest.
Most of the diseases to which I have referred are germ diseases, to be attacked by the weapons of Pasteur and Koch. There are other diseases which in contrast with these more acute infectious dis eases may be called degenerative or chronic dis eases, such as hardening of the arteries, cancer, Bright's disease, and organic diseases of the heart. Referring to this distinction in an address before the American Public Health Association in De cember last, Professor Irving Fisher made this generalization: When we analyze the nature of the present improvement, we find it due chiefly to a de creased loss of life from infection before middle age in spite of an increased loss of life after middle age from degeneration. There is thus a race between two tendencies, a reduction in the infectious diseases and an increase in the so called degenerative diseases.
The increase in the diseases of later life is to be accounted for partly by the decrease in the dis eases of earlier life. If we do not die of diphtheria,
scarlet fever, or measles, we survive to an age in which we are likely to die of cancer and arterio sclerosis. If we do not die of tuberculosis in early manhood, the vital organs have a chance to wear out. To be sure it is not to our credit that they wear out prematurely, and the time has apparently come to concentrate on personal hygiene some of that same kind of attention that we have given to sanitation. There is no need to diminish the one in order to increase the other. Probably the next great step ahead in the protection of public health is the working out of some plan by which every person shall be periodically examined. The Life Extension Institute presents one plan to carry this idea into effect. Health Departments may come to offer such examinations free to those unable to pay for them.
The philosopher Dooley makes his favorite char acter, Dock O'Leary, complain that he is not a very muscular man and that "some of the windows in these old frame-houses are hard to open." "He says the more he practises medicine th' more he becomes a janitor with a knowledge of cookin'. He says if people wud on'y call him in befure they got sick he'd abolish ivry disease in th' ward except old age and pollyticks. He says he's lookin' forward to th' day whin th' tellyphone will ring and he'll hear a voice sayin', 'Hurry up over to Hinnissy's; he niver felt so well in all his life.' 'All right: I'll be over as soon as I can hitch up th' horse. Take him away f'm the supper table at wanst.' " Sickness insurance, taking the form, so far as wage-earners at least are concerned, of social in surance under state control or supervision, is the approved modern method of distributing the finan cial burden of sickness. England and Germany ( have both developed very complete and successful, \ though very different systems of state sickness in \ surance. We shall have to work out the problem on somewhat different lines from either, probably adopting some of the features of each; but work it out we must in our own way, for the hardships and inequity of our present lack of system in this matter will not long seem tolerable.
Sickness insurance seems to me a more pressing problem in this country than old age insurance or unemployment insurance, more necessary than mothers' pensions or any other form of public relief. It should cover, as it does in European countries, maternity insurance and life insurance on an ampler scale than our present industrial in surance companies provide. The expense should be divided between the insured and his employer, who will have the same opportunity to pass his part on to consumers in the form of slightly higher prices that he has in the case of compensation for accidents. If necessary, the state can assume a part of the cost, as the prevention of sickness and the distribution of its burdens is properly a public function.
Sickness insurance does not of necessity mean sickness prevention, but it is easy to unite the two harmonious and closely related policies into a con sistent policy of sickness insurance and prevention. A Federal Health Department, vigorous state Health Departments, even more energetic and well supported local municipal and rural health boards, all engaged in a well-knit campaign of prevention and education, will be outward and visible signs of that public health ideal of which sickness insurance is another normal expression.