The Economics of Health (1918)
This article appeared in The Economist on December 21st 1918
IT is evident that any financial damage inflicted on the country by the war can best be repaired if every individual works to the fullest extent of his productive power. Productive power, however, depends on physical and moral efficiency, and war statistics have shown that the ordinary Briton falls lamentably short of even a lenient standard of physical fitness. The recruiting figures can be used for industrial purposes, for if a man is not fit for fighting he is not fit for full normal industrial productivity. The country has lately been told that – (1) the standard of physical efficiency is lower in England than in France, Germany, or any other of the great belligerent countries; (2) if adequate attention had been paid to health this country would have been able to put a million more men into the fighting line, and the war could have been won speedily without the combing of essential industries. The present shortage of fuel and food should be recognised by every householder in the country as attributable in some measure to the low standard of health and fitness which we have been content to accept; (3) only one-third of the men of military age (the period when the maximum of physical strength can be expected) examined under the National Service Ministry were found to be Grade I. To give this last fact its full value, it is well to state the official definition of Grade I. “A Grade I man is one who attains to a normal standard of health and strength, and is capable of enduring physical exertion suitable to his age. He must not suffer from any organic disease, and must have no grave physical disability or deformity.” The Grade I man, therefore, is not a superman: he is merely normal. The remaining two-thirds are sub-normal. These latter, as citizens and workers, not only fall short of their full productivity, but have to spend money on drugs and medical assistance to keep at work. Some idea of the loss to the country in their lack of full productivity can be gauged by the instantaneous effect on supplies of a strike or of two or three days’ jubilation on the part of the miners. A corresponding estimate of what must be spent on keeping them at work could be reckoned from the Army figures of the sums spent in treatment and maintenance of men fallen sick who entered the Army in cate- gories lower than Grade I.
It will always be difficult, however, to give satisfactory figures in evidence of the economic value of health to the State, because health is dependent on such an extricable tangle of causes. At the present time, moreover, very few people have thought it worthwhile to investigate the matter, but certain factories under the control of the Ministry of Munitions have made a start, and their results, while still very incomplete, serve as an indication of what may be expected and of the difficulties to be encountered.
The experience of these factories is that, roughly speaking, 5% of available time is lost through ill-health, and that of this amount 80% is attributable to general sickness and 20% to accidents. But some of the accidents are occasioned by nervousness and lack of control arising from a low tone of health on the part of the worker, and, on the other hand, some of the sickness recorded may have originated in an accident. Evidence more tangible is offered by the influenza records noted during the summer epidemic (not the recent one), which show that about 36 hours a head of the munition-making population was lost, involving a loss to the community equivalent to that of about four working days.*
Another suggestive field for computation is afforded by actuarial figures showing that the average expectation of life is not more than 53 years. Still further interesting investigations could be made into the profits made by druggists and the number of men employed in that trade.
But this is not all. If the country is losing by not getting the full productivity of men and women who are still able to do something and earn a living, what of the others who can earn nothing but who must, nevertheless, be maintained at a dead loss?
In 1914 there were 17.0 per thousand of the population receiving Poor Law relief. The Poor Law expenditure was nearly 15 millions, or 4s. per head of the population. These figures do not include hospitals, nor Old Age Pensions (a large proportion of which formerly appeared under Poor Law expenditure). An instance of such non-productive expenditure was recently recorded by the Newton Abbot Guardians, who stated that a man had died under their care upon whom they had had to spend a sum well over £1,000. Not only was this man non-productive, but he was using up a portion of the national income as well as the attention and time of the highly and expensively-trained people who were looking after him, and whose energies could have been employed to more useful account.
It may be argued that pauperism is not sickness, but the experience of the Guardians is that 50% of the relief they dispense is for actual sickness. A large proportion of the remainder is given to cases who have come to the Guardians in the first instance for help in sickness, and who have thenceforth relied on them for further relief.
It is incontestable that a thorough reform of national health will require a large expenditure; but expenditure upon it, if well and judiciously made, will pay as handsomely as a business proposition. As an offset against the money required must be placed a reduction in the Poor Law, in National Insurance, and in the cost of hospitals. Of the latter there are 2,634 in existence, exclusive of tuberculosis sanatoria, convalescent homes, nursing homes, hospitals for chronic cases, and sanatoria attached to schools and institutions.
What practical steps, then, must be taken to build a nation strong in nerve and sinew? To continue to devote unremitting care to those who have been crippled by the evils of our social system is merely to pay the penalty for past slackness. It must be done, but it is not progressive work.
The health work initiated by the Public Health Act of 1875, at present administered by the Local Government Board through the local authorities, must be developed and co-ordinated. It aims at preventing disease, and includes, amongst other activities, sanitation, factory and nuisance inspection, notification of certain diseases, instruction in health habits, inspection of food, notification of births, registration of midwives and of foster-mothers, provision of maternity homes, dental clinics, venereal disease clinics, compulsory disinfection after infectious diseases, provision of public wash-houses and cleansing stations.
Further developments in preventing disease are foreshadowed by the work of the Medical Research Committee, whose report (1917-18) has recently been published. This committee gave warning of the pandemic of influenzal pneumonia; they investigated T.N.T. poisoning to such good effect that only one girl worker was affected by it this year. They have studied dysentery and malarial infections with an equally good result, and they advised a treatment for cardiac complaints which has saved the State in one hospital alone a sum of £50,000, “an amount closely equivalent to that of the whole of the Medical Research Fund which the committee are privileged to administer.”
But it is not enough to cure disease, nor to labour at preventing it. Our aim must be to establish a standard of positive good health, and this goes to the very root of those vexed questions – housing, wages, and hours of work. The National Service records, fragmentary as they are, serve as a basis for inquiry. This department state that they found the fittest section of the population to be the young miners. Their work is hard physically, but they earn wages sufficiently good to allow of their working short hours. They eat good food, and their recreation of coursing gives them the open air they need without any further physical effort.
War must be waged on such conditions by State and employer alike. The employer has already learnt that output depends on the physical efficiency of his workers, and he is ready to do his share in his own interest if for no better reason. Decent conditions of work, fair pay, and good housing will do much, but not everything. We come back, as almost always, to education, and the individual’s views and ideals. Until we all know how to be healthy and strong, and recognise that unless we are so we cannot pull our weight in the boat, and that pulling our weight in the boat ought to be one of our chief objects in life, a low standard of health and efficiency will continue to be a drag on the nation’s productive power.
*British Medical Journal, November 23rd.