MEDICAL NEEDS

Medicine has developed, up to the present day, as a contract between the individual patient and the individual doctor. This has been a very long process and at varying stages in history different non-medical agencies, particularly the Church and the State, have entered the medical field in order to make provision for groups who appeared to be outside the range of ordinary medical treatment. Some of these changes have curtailed the liberty of the doctor to act as an individual in one way or another, while others have bound the patient to a par­ticular form of medical service. In their essentials, however, all have attempted or pretended to maintain the personal relation between the doctor and the patient, and the doctor of to-day still feels himself largely bound by the same conceptions as those which governed the work of Hippocrates, to whose tenets indeed every medical student has sworn for more than two thousand years.

This attempt at maintaining the personal relationship in medicine has, however, been almost entirely falsified by the development of modern medical science, and the change has been especially rapid in the last fifty years. To-day it is true to say that while many doctors appear to work as individuals, with no bonds of co-operation with any other practitioners, neverthe­less every doctor is only a small part of a vast net-work of medical agencies without whom much of the best work done in medicine would be impossible. It is probably true that eighty-five per cent of patients consult the doctor for conditions with which he is able to deal himself, but it is equally true that almost one hundred per cent of the population do, at one time or another, require the services of other medical men of consultant standard, or of some of the other forms of medical care.

There are, for example, large numbers of hospitals ranging in size from a few beds in a rural area to the great institutions in our medical teaching schools and in our municipal hospital services. There are clinics in great variety, some run and con­trolled by voluntary agencies, the greater number in charge of local authorities. In all of these there are varying amounts of elaborate apparatus, of X-ray machines both for the diagnosis and the treatment of disease, and there is all the electrical machinery used for other forms of treatment and for the examina­tion of the heart and nervous system. There are the hospital laboratories equipped for carrying out an ever growing range of tests, and there are great research institutes employing hundreds whose duty is to discover the causes of disease and more efficient forms of treatment. In the background there are all the manu­facturers of medical products, many of whom in their turn maintain their own research departments to which medical science owes some of its greatest advances.

Nor does the network of medical agencies cease at the frontiers of countries, for until German Fascism closed the greater part of Europe to the knowledge and skill of other races medicine was the most international of mankind’s activities. Few dis­coveries were made in any country without being immediately communicated to all others, and many great discoveries have been due to the co-operation of men living and working in countries very far apart, men who very often had only the one bond—the service of the sick.

This co-operation in the medical profession of all countries has been a conscious development fostered by many international societies and by the readiness of individuals to pass on not only their own results and observations but any experimental material that they may have. It is for example of interest to note that there is in London an international collection of cultures of all types of bacteria, and many of the strains that have proved most useful to experimenters in this country have first been discovered in laboratories abroad. The ordinary sick person in time of trouble is unconscious of this network of medical services, but it is there, and in some way or another at his service.

There would be very general agreement that all the types of medical service we have mentioned are required at the present day. There would also be complete agreement that the whole of this machinery for dealing with disease should be available to the whole of mankind. The basic principles on which medical service should be rendered and on which medical care should be built would probably be accepted by all thinking people in any part of the world. Disagreement arises, however, as soon as the form and detailed structure of a service which could provide all the advantages of medical science are discussed. It is that form and structure which we propose to discuss here, but it is first necessary to state those basic principles which we believe will be generally recognised as the essentials of modern medical care.

There are many ways in which medical care can be studied, for the doctor, the state, local authorities and many voluntary agencies all have their points of view, but the only way in which the real fundamentals can be stated are from the point of view of the patient. So many discussions, particularly among medical men, pay only lip service to the need of the patient and discuss the subject in reality from the self-interest of the doctor, and while we must examine at a later point the needs of the medical personnel in any scheme that may be suggested, the service is for the sick and it is from their point of view that we must begin our examination of the case.

Taking into consideration the whole of life, the many dangers that are incurred and the many problems that arise in modern conditions, the individual citizen has a right to demand from the medical profession a service which gives

• health protection
• disease prevention
• detection and diagnosis of disease
• treatment and cure of disease
• health restoration
• health education.

Each of these points will be examined in greater detail but we must at this point summarise something of what each implies. The implications indeed carry us very far afield and demonstrate the tremendous importance of medicine in human activity.

The first essential is health protection and this involves the consideration of every environmental factor. We cannot even assume that every individual is born in a state of health, for a very large number of babies arrive in this world with some defect or another, and the protection of health must therefore take into consideration the health of the mother and, so far as truly hereditary deficiencies are concerned, the health of the father and even of the grand-parents. For those who are born with some defect we may be able to offer only the type of medical service which begins with the detection of disease, but for the vast number who are born healthy the primary duty of medicine is to protect that health against every possible form of disease. This health protection involves a consideration of such factors as housing conditions under which the people live, the con­ditions to be found in our schools, and later in life the conditions in industry. Throughout the whole of life there is need for understanding the effect on health of inadequate nutrition, and until the medical profession can say without hesitation or difference of opinion that one hundred per cent of the population receive one hundred per cent of the food that is required to maintain health the profession cannot claim that it is providing for the health protection of every individual. The citizen must, however, play his or her part in this department of medical care, but cannot be expected to do so without that education in health matter which we have listed last among these principal points.

Disease prevention is not in any way identical with the protection of health. The latter is a general question of fitting the individual to meet the conditions of his or her environment, while the former is the application of scientific knowledge to the prevention of particular diseases. This is again a very wide subject and involves us in considering methods aimed at protecting a particular individual from the risk of a particular disease, for example devising a method of preventing an explorer in a tropical country from contracting malaria, to the protection of whole masses of people from wide-spread danger as in attempting to avoid a world-wide epidemic of influenza. The methods to be employed are again of varying type; there are those that can be applied over a wide-spread area and based on similar considera­tions to those mentioned under the heading of health protection because they are aimed at changing some condition in the environment which increases the danger of disease. In addition there are those which aim at providing complete immunity to a particular disease in a mass of people running a particular risk as in the case of immunising the army against typhoid fever or immunising school children against diphtheria.

The detection and diagnosis of disease is a purely medical problem, and although there are a few points in the case of epidemic disease in which the occurrence of certain symptoms among a large number of people may be of diagnostic importance nevertheless the detection of disease is largely a matter for the individual doctor and the individual patient. Even in this field, however, the number of factors involved is quite large. There is, to begin with, a question of the ability and of the training of the individual doctor. There is the question of his possessing that type of personality which obtains ready co-operation from the patient, and there is the ability, or more commonly the inability, of the patient to describe accurately and helpfully how he is affected by ill health. Given a certain minimum of medical knowledge the doctor has to consider all the organs of the body and how they react to different diseases before he can make any attempt at diagnosis. If he is in doubt and is faced with a case of great rarity or difficulty he then requires the services of other doctors who from their special knowledge or their ability to carry out special methods of investigation, or their possession of apparatus which is expensive and therefore cannot be in the hands of every doctor, are able to make a diagnosis with greater certainty. So variable is the reaction of the human body to disease that quite a large number of patients go into hospital in the first instance for observation and diagnosis. It cannot be denied that there are many patients who are treated, at least for a time, without their doctor having made a diagnosis with absolute certainty, but on the whole doubtful cases are usually sent in to hospital where they can be more closely watched and more carefully studied. That this is necessary no one will doubt, for correct treatment depends on correct diagnosis.

The treatment of the sick person is also a purely medical problem and one which should not be undertaken, and indeed should not be legally permitted, except by those who are recog­nised to have a complete understanding of all the multiplicity of diseases that attack the human body; but treatment is very often something which the ordinary general practitioner could not carry out entirely by himself, for modern methods of treat­ment involve the use of drugs and chemical substances of the most elaborate nature and in an astonishing variety. The evolution of modern treatment has involved the work of a very large number of scientists from many other fields, but par­ticularly of the chemist who in co-operation with the doctor has given us drugs of remarkable potency.

When a patient has suffered from disease or injury he may or may not be restored to complete and perfect health; there are many conditions of which it is true to say that the body recovers so completely that no recognisable variation from normal can be detected afterwards. There are many, however, which leave their mark and from which only an incomplete recovery is possible. In either case the patient should be given every assistance to reach the maximum possible degree of recovery with the greatest possible rapidity. Developments in this sphere are likely to mark the next stage in the evolution of medical science, for it is only now recognised how beneficial can be the effect of a rehabilitation scheme for the sick and injured. In industry it is absolutely essential that the return to work, particularly after injury, should be made at a rate and under conditions which restore the body without raising new stresses which may produce other damage. Fortunately the human body has tremendous recuperative powers, but the medical profession has been prone to accept this recuperation as a fact without doing anything to enhance it. In this respect probably more than in any other medical care has been held back by economic considerations. These economic considerations can only be removed and prevented from interfering between the doctor and his patient by the setting up of a nation-wide machinery for this purpose.

Our last point is that of education in health matters. There has been in this century a very considerable change in the attitude of the general public to questions of health, and there has developed an enormous demand for information about the human body and about ways in which health can be maintained. The medical profession unfortunately has, by its lack of organi­sation, been quite unable to recognise this demand or to cater for it. We have seen, therefore, a flood of literature on health matters which has almost entirely been linked with the selling to the public either of apparatus, food stuffs or drugs claimed to have a special function in preserving normal health, or with ideas on the cause of disease not in line with modern scientific thought. It ought, however, to be one of the functions of the medical profession to furnish to the public accurate and easily understood information as to the cause and recognised method of treating disease. Health protection will be quite impossible without a considerable and constant volume of propaganda on what health means. When this propaganda is done by the profession as a whole the relationship between the doctors and their patients will become closer, and co-operation for the health of the individual and of the nation will become easier.

We have suggested that these basic principles carry with them implications of the greatest importance. One of these implications is that however medical care is organised it must be complete for every individual in the country, and must be available without the intervention of any economic, social or racial barriers. It has been the existence of these barriers which has in the past prevented the development of any form of organised medical service and has constantly prevented the individual doctor from giving the very highest service of which he is capable, and has prevented very large numbers of the people from benefiting from all the discoveries of twentieth-century medicine.