The Future of Medicine 11 The quest for perfection

Whatever form the medical service of the future takes it is very necessary to avoid the building up of a system in which one or other of the sections of the community has a pre­dominating interest or control, A scheme might be initiated which would fail because one of the groups concerned de­clined co-operation. It is, for example, well within the bounds of possibility that the medical profession might refuse to co-operate with the State in supplying the type of service which the State had decided was necessary.

Despite all that has been said or written about the altruism and ability of doctors as a whole, there have been occasions when what they conceived to be their interests have brought them into conflict with the rest of the community., When National Health Insurance was first proposed the whole country welcomed it as agreat social reform, but the profession opposed it from every possible angle. This opposi­tion was maintained up to the point at which it became clear that the Government and the country were determined that ; the: benefits proposed under N.H.I, should become available at once, and when it was apparent that further opposition was obviously useless the doctors capitulated, Having accepted the system, it must be said that the profession soon acknow­ledged that not only was it a step forward for some parts of the community but of tremendous financial benefit to the doctors.

Today in many parts of the world we are witnessing, a similar contest between the medical profession and the community. In America the official representative body of doctors, the American Medical Association has had to face the courts on a charge of interfering with the right of citizens to make their own arrangements for medical service. In New Zealand the British Medical Association held up for many months the institution of the medical service provided for in the Social Security Act and for which there is over­whelming support among the people of that dominion. This struggle has yet to be settled but it has already been stated that, as happened m the case of the Panel System, the opposition of the profession will disappear when the community shows its determination to establish a medical service. In that case it is to be expected that the predominating interest of doctors —the welfare of the patients who call upon them —will lead the profession to give their services ungrudgingly, and to acknowledge in the course of time the benefits which have accrued.

So far as this country is concerned, the amount of unrest in the medical profession is so great and so widespread that any serious disagreement between the doctors and the com­munity may be avoided. We have at this moment the British Medical Association Medical Planning Commission, the many councils and committees set up by the Nuffield Provincial Hospitals Trust, and the Emergency Medical Service for dealing with air raid casualties, all of which in combination with the great changes that moving populations have brought about may force upon us rapid and far-reaching develop­ments. If this occurs while the war is still going oh, the medical profession, will not only feel that they are not in a position to oppose the community but, as the evidence from a great variety of sources indicates, would gladly accept some new form of medical organisation.

If the changes are long delayed and the community does not itself demand a real medical service, the next stage in medical history may not be reached until the needs of the modern world have compelled changes in the education of the doctors themselves. In particular, it is recognised that a change in the medical curriculum, which has been subjected to much criticism in recent years, would alter the attitude of new doctors towards disease and lead them to realise the importance of preventive medicine and the extent to which health and disease are affected by social conditions. It is undoubtedly true that changes in the structure of medical practice such as we have discussed would involve important changes in medical education. As soon as medical service became one of the functions of the State it would be clear that the selection of those members of the community who were to be trained as doctors could no longer be left to the present haphazard methods of choice, but that the State would require to make medical education available to every student who showed a likelihood of making a first-class doctor. Facilities for medical education could easily be in­creased by using more of our hospitals for teaching purposes, for at the moment only a very small proportion of the medical material available is used in this way. While it may be true to say that at the present moment we have too many doctors to enable them all to earn a rich living, we certainly have too few :to give this country (and the other parts of the world which draw on our medical schools) anything approaching a complete medical service.

Criticisms of present-day medical education are both technical and general, and students themselves are taking an active part in discussing what changes are necessary. On the technical side the National Union of Students has already suggested that the training does not relate the earlier studies of the medical course to the later needs of the doctor, that too much time is spent on the acquisition of detailed know­ledge while their background of general biology is completely absent, and that the present-day teaching of anatomy and physiology produces a divorce between a student’s knowledge of function and of structure which is hardly corrected by his later tuition. Medical teachers have also pointed out that there are only a few of our medical schools in which contact between the doctors of the future and those training for other professions is sufficiently intimate to give the doctors a cultural background. This is of immense importance today when it is realised how vital to the future of the world is the spread of what would have been called in earlier days a liberal education.

Of the greatest importance to the future of Medicine is the need for giving every medical student a clear picture of the social background in which disease occurs. There is no direct teaching of this subject in the medical curriculum, and even the relation of industrial hazards to ill health and accidents is not taught in a way which would influence the average student. Many of them obtain their first knowledge of how a large proportion of our population lives when they take their course in midwifery and go out to see cases in the homes of the people. To those doctors on whom such experiences have had a: lasting effect it appears strange that so many medical men can go through their professional careers without realising the relation between environment and, disease. Their early upbringing and their medical training have in some way insulated them from this knowledge. On the other hand the same doctors would agree in the course of technical discussions inside the profession as to the profound effects of environmental conditions. As a body the profession is, in fact, well aware of the social and economic im­plications of many of the diseases with which they deal. As Professor Sigerist puts it: ” We know what should be done in Medicine; We all know that slums spread tuberculosis, that unemployment leads to prostitution and to the spread of venereal disease that under-nourishment cripples children. We doctors all know that, and yet we are helpless under the present system. Whenever we attack such problems we run headlong into insurmountable economic barriers. Medical science has progressed more in the last fifty years than ever before in histor and yet we run the risk of seeing Medicine wrecked by its own progress because we have put all our efforts into increasing our knowledge of Disease while we have steadily neglected the social side of Medicine.” These are questions upon which the medical profession itself must initiate changes ; and there are many others.

In some way the profession must find a method of constantly checking up on the ability of its members. At the moment all that it has done is to try to regulate certain aspects of the doctor’s moral behaviour. In this cpuntry today ” the doctor who carries out the letter of the law and does not offend against its prohibitions may still be neither a good nor a morally sound physician.” To make him a better physician than he is today must be the principal endeavour of medical education of tomorrow.

We must, however, return to the problems of the citizen. There is always a possibility that the citizen may refuse to accept new methods and new ideas even when to those who have introduced them they appear to be vitally important to the citizen. So far as the provision of a complete “disease” service is concerned the really sick person will readily accept all that is provided. His one concern is to defeat the disease that afflicts him and to make as rapid a recovery to health as possible. In acute illness he does not much mind who treats him or what kind of hospital he is nursed in, but he must of course be benefited if he is conscious that the service is the finest which can be provided.

What is required, however, is the co-operation of the citizen in health, and the establishment of a completely new attitude towards disease, a freeing of sickness from super­stitions, and a realisation that when a human being is sick it is because of some traceable and probably removable cause. To understand this it is not necessary to give everyone an education in hygiene or even in simple science. But, as Lord Horder puts it, “people must be educated up’ to a desire to be healthy units of a healthy nation.”

This is no simple problem; the inculcation of a new attitude towards health in a population as varied as that of Great Britain will bring the medical service, on which the duty of educating the public must fall, in conflict with a great variety of interests. There are, for example, those advertisers of proprietary remedies who depend for their sales on making the public conscious of some disease, real, imagined, or invented by the advertiser, of which there is an infallible cure to be obtained at a price. A conflict may also ensue with those holding ethical, religious, dietetic, and pseudo-scientific views as to the cause of disease. There may also be conflict with those who preserve the modesty of the Early Victorian era and do not allow discussion in public matters relating to health. The simplest fact in medical science may produce reactions of a most amusing kind. As an example one may mention a recent attempt of the Ministry of Health to arouse the interest of the people in avoiding war-time dangers. One of these dangers is the spread of typhoid and related fevers and on purely scientific and demonstrably true grounds; the Ministry thought that the public should know that one’s own safety and that of others would be increased by the simple process of washing the hands after using the w.c. What are we to think of a country in which this simple advice was considered too outspoken, and the Ministry of Health’s advertisement refused by some of our newspapers? These minor difficulties in giving the. public a new attitude towards its own health can be overcome. A greater difficulty arises from the social background in which the people live. It is quite impossible to instruct people in the maintenance of health if they are in fact, as so many millions of our popula­tion are, living in houses which do not provide those minima of air, light, heating, water and other supplies which medical experts would regard as necessary. It is useless to speak of the value of certain foodstuffs if the price puts them beyond the reach of any section of the community, and hopeless to discuss the advantages of taking exercise among people living in large cities where the opportunities for such exercise are almost non-existent. It is certainly impossible to persuade the workers to attend for regular health examinations if as a result of discovering minor defects they will be forced to stay off work for the necessary treatment, thereby losing employ­ment and income. It would be useless to advise people to avoid unnecessary risks and strain if they are employed in an industry which is in itself a danger to health. It will, in fact be quite impossible to persuade the average citizen that health is one of the rights of man but that he himself has the power of maintaining it or ruining it, unless he is at the same time made aware that everything which threatens his health from without is being removed by those responsible for the removal.

Responsibility for thus improving the environment in which all of us live must be assumed by the medical pro­fession. It may be true “that millions of pounds are spent in looking after and trying to cure the victims of accidents and illnesses which need never have occurred if a fraction of this amount of intelligence and money had been devoted to tracing the social and economic causes of the trouble.” This research, into the social and economic causes of disease has never been tackled by the medical profession as a whole, and those individuals who have conducted investigations have not always been received with favour. This lack of favour is due, of course, to the tremendous implications which result from any such medical inquiry, for they would mean interference with such things as our “habits of life, the lay-out of our towns and buildings, labour management, transport, food manufacturing and distribution,” and, one might add, would ‘involve decisions on such questions as eugenics, birth control, and family allowances. But the medical profession cannot avoid this responsibility much longer, and if it is to achieve full stature it should be in the forefront of those political and social changes and experiments, instead of arousing in many the fear that it may prove a hindrance to progress.

In the end, however, it is the community and the individual citizen who must build up their own fitness and improve the health of the nation. It must no longer be considered morbid to take an interest in one’s own body and in its functions. There have been many strange cults whose methods have sometimes been amusing and without any scientific basis. Their belief in the power of man to maintain his own bodily , strength and fitness was, however, a valid one. It is impossible at this moment to visualise a world in which disease plays no part, and certainly there is no evidence that however much man strives after health, and however medical science ad­vances, those diseases of old age which finally lead to death can be overcome. What we can say is that if medical science is given a chance by linking organisation with research and constant advance, and if man puts his trust in such a service and supports it by his own actions in every possible way, then we shall be able so to reduce the incidence of disease that it

will come to play but a minor part in the life of the munity and will enable all to; achieve for the longest possible period a standard of health and a joy in living that they may say;

We have made of Life a lovely thing

And spread the grandeur of its wing

Above the sea of Death.