Death And The Dollar
( Originally Published 1952 )
'For all .. the right to adequate medical care and the opportunity to achieve and enjoy good health.' (From Roosevelt's 'Economic Bill of Rights')
'Thousands of ill and needy New Yorkers are being deprived of hospital care.... An estimated 20,000 persons with active tuberculosis are unable to get into hospitals because of lack of beds.'
New York Times
March 5, 1948.
ONE OUT OF EVERY FOUR AMERICANS WHO DIED IN THE prosperous post-war years might have lived. Not that American medicine, in many respectS the world's beSt, haS been unable to save the infantS and young mothers, the boys and girls and men and women who did not fulfil their normal span of life. What has been killing them —at the rate of one every one-and-a-half minuteS each day and night of every year—was poverty.
`Every year, over 325,000 die whom we have the knowledge and the skills to save. . . . Of more than 3,800 deathS that occur daily, nearly 900—about 23 per cent—are preventable', Oscar R. Ewing, the Federal Security Administrator, reported to President Truman in 1948, after the National Health Assembly had examined the great lack of medical care in the country. 'Much of the sickness that cuts down the efficiency of the Nation's working force can also be prevented. . . . Every year the Nation loses 4,300,000 man-yearS of work through bad health . . . and $27 billion in national wealth.'
There are as many deaths needlessly suffered each year as it would take to wipe out the population of Switzerland in fifteen, or that of Boston in a little over two years. It iS as much labour wasted each year by illness as is normally at work in the entire Netherlands; or as much as America uses in all her huge mining, iron and steel, metal, machinery and automobile industries. It is as much wealth lost each year as is produced in the whole of India; or three times aS much as Americans spend on medical care, burial expenses and the upkeep of cemeteries.
What leaves such an appalling health problem unsolved in the world's richest nation is of course not only, or even mainly, the surprising lack of proper medical treatment and public health care.
Deficient food and shelter and all the other unfilled needs that go with substandard incomes and with the almost inescapable publicity inducements t0 useless or even harmful spending are more basic reasons for so much illness and theref0re for so many unnecessary deaths.
The close relationship between low earnings and poor health was already established before the war by the Public Health Service. Families with low incomes were found t0 suffer nearly four times as much disability from tuberculosis as those with middle class incomes, nearly three times as much from orthopaedic impairments, and twice as much from rheumatism, digestive diseases and nervous ailments.
But the lack of medical care is great and its cost beyond the reach of many. The Committee for the Nation's Health estimated in 1947 that altogether 97 million out of some 140 million Americans did not have the means to obtain adequate medical attention; and the Ewing report confirmed that 'by and large only the well-to-do and, to a certain extent, charity patients get satisfactory medical care'; so that 'a scant 20 per cent of our people (families with $5,000 a year) are able to afford all the medical care they need'.
Before the second world war America ranked only sixth among the nations with relatively low infant mortality rates, eighth in maternity mortality, and fourth in the average life expectancy at birth of its `white' babies—to say nothing of the much shorter life expectancy of `coloured' infants. No new facts indicate a basic change.
Already in 1945 President Truman told the nation that lessons must be learned from the alarming fact that over 30 per cent of all men examined for war service proved unfit physically or mentally, and that a further 10 per cent had to be discharged later for various disabilities. Yet p0st-war draft rejections were even higher; and when the once disqualified men came up again for examination in the late forties, it was found that very little had been done in the meantime to treat their maladies.
On June 12, 1952, the Selective Service Director stated, according to United Press, that nearly 45 per cent of drafted men had to be rejected since June 1948, and that the health of the nation's young men was 'less favorable now' than during the second world war.
Post-war America is richer than ever but continues to spend ast0nishingly little on her health. Total expenses on medical care amount to barely half the waste in gambling.
The nation has only four-fifths the number of physicians and surgeons that might suffice if they were well distributed over the country and fully used. The lack of dentists and nurses is even greater. While the rich state of New York has one physician for each 500 persons, Mississippi with its inferior transportation system has only one for each 1,500. California has one dentist for each 1,300 people; South Carolina only one for every 5,000. Wealthy Connecticut has one nurse for each 200 inhabitants; Arkansas, in the South, only one for every 2,100. Super-specialized America has barely one-third the needed children's specialists, and for the sixty per cent of her children in small towns and rural areas there are none. In twenty-five of the forty-eight states not one community has a child guidance clinic.
The prospects for more medical personnel are dim. Teaching facilities are chronically short, training expenses out of reach for many students, and organized medicine is more eager to restrict competition than to provide fresh medical manpower for the under-supplied, rapidly growing population.
If 'free enterprise' continues to decide how many people are to survive or die, get cured or suffer needlessly—the Ewing report estimates—America, by 960, will be short of 42,000 physicians, 23,00o dentists, 163,000 nurses, and 60,000 well-trained public health workers. There are only half as many hospital beds as the minimum that would be needed on the basis of adequate distribution; but distribution is unequal and two-fifths of all counties have no acceptable general hospitals. Even in New York City many of the sick were without hospital care, the New York Times reported on March 5, 1948, when 0,00o patients with active tuberculosis, a menace to the rest of the people, could not be hospitalized because of the lack of beds. Yet at the current rate of hospital building, states the Ewing report, 'we will meet 1946's needs in 1986-40 years too late'.
Medical research, despite its achievements, is lagging behind America's potentialities, in chronic need of three-fold larger funds. For, of the $1 billion a year the nation spends on research, 'only a little more than 10 per cent' benefits medical and related sciences.
It is indeed, as the Ewing report puts it, a 'situation incompatible with our position as the world's leading democracy', a 'total effort for health completely out of pace with our expanding economy'. But American voters were not moved to action by this shocking document. Most of them never even heard of it. The press is partly to blame for the fact that this well-written, attractively presented publication of the Government Printing Office, at $1 a copy, did not find one-hundredth of the readers who made a best-seller of the highly technical, expensive `Kinsey Report' on the sexual behaviour of the American male.
That people die from economic causes is not the kind of news the popular press splashes over its front pages and dramatizes in heartrending interviews with relatives. For this, death has to be of a different kind, for instance like that of Kathy Fiscus, the little girl who fell into an uncovered, abandoned well on a California oilfield and was found dead after several days of valiant rescue attempts. In that case, special correspondents were flown to the scene, whole pages were filled with detailed news and photographs that whipped up the sympathies of the masses, and moving editorials launched a powerful popular movement which quickly forced a law through the California Legislature making it mandatory for the oil companies to cover abandoned wells.
Had proof been needed how much the press can do to mobilize an impressionable nation's dormant passion for the saving of life, it was provided by the editorial the New York Times wrote on the occasion.
ONE LITTLE GIRL
'A little girl was dead. That was the news—just one little girl. Three days ago only a few people knew the name of this little girl. Yesterday there was no one in this country and few in other civilized countries who had not heard of 3-year-old Kathy Fiscus of San Marino, Calif. Millions upon millions followed this heartbreaking story as they did no other news of the day. This morning those millions share the grief of Kathy's parents.
'Yet even Kathy's father and mother must have felt that something like a miracle of human compassion had taken place. Their little daughter had suddenly become a symbol of something precious in all our lives. The world is overladen with great problems. Two great wars and many smaller ones have cost the lives of multitudes, including little girls just as dear to their parents as Kathy was. But we still know, even if the mad theorists at the other side of the world do not, that one life—one tiny life—is beyond price. Kathy came close to our hearts and made us one. A splendor of unselfish emotion lit her path as she went from this earth.'
Why did such 'splendor of unselfish emotion' never light the paths of the victims of poverty who were going from the rich American earth at the rate of one every minute-and-a-half--those who did not have .the money to see a doctor in time, to get the treatment they needed, or the food and shelter that might have preserved their health and saved their lives? For example, why were not millions made to share the parents' grief over a little boy 'just as dear as Kathy was', two-and-a-half months old Earl Everingham of Atlantic City, who starved to death? Was it perhaps because Earl could not have been used, as Kathy was by the New York Times, to serve as a little soldier in the Cold War?
Earl Everingham's father, 'a twenty-nine year old war veteran, hitchhiked home last night from nearby Bridgeton in pretty good spirits. He had got a break for the first time in six months . . . a job . . . and in his pocket was $ 1o, an advance against his salary. The money was sorely needed. He had sent money home twice during the week he had been away job hunting ... twenty-five cents one time, eighteen cents another . . . to buy a little milk for the babies.' But the war veteran came home too late. 'His infant son had died that afternoon in Atlantic City Hospital. Malnutrition, they had said at the hospital, undernourishment. "Starved", Everingham said bleakly, "the poor kid starved." That was it. . . . The physician confirmed it.'
The New York Herald Tribune conscientiously reported this miscellaneous event. But not the popular press with its multi-million circulation. There was no nationwide 'miracle of human compassion' with the child's father who had fought for his country a mere few years before and since then struggled with joblessness. Why was this case not followed up and hammered home in poignant editorials until action was taken by the legislators to cover the wide-open death traps of poverty, just as they had made the California Legislature cover the death traps of abandoned oil wells? The head of the Atlantic City chapter of the American Red Cross gave at least part of the answer when she commented on the case of the war veteran's son who starved to death: guess it was a case of everybody's business being nobody's business.'
Health care for the masses of the people—that is politics, the concern of vested interests, of a great profession strictly organized on a business basis; a matter on which emotion must not be allowed to enter unless it helps to beat the drums for 'free enterprise' in medical care, to frighten the people of 'socialized medicine'.
For weren't President Truman and his Federal Security Administrator playing politics when they publicized those figures about `unnecessary deaths'? Weren't they trying to foist 'alien' thoughts and practices on America when they followed up their grim statistics with a fresh demand for national insurance? Weren't they, like Roosevelt, attacking and undermining the qualified protector of the nation's health, the A.M.A. (American Medical Association), with activities little short of subversive?
It is true, unfortunately, that President Truman and Mr Ewing, one of the Democratic Party stalwarts, were trying to catch votes with their health campaign, turning it on full steam when elections drew close, turning it off when they were over, and never mobilizing for their proposed legislation the powerful popular support they could have mustered. But its undoubted exploitation for party politics does not take away from the justness and urgency of the cause of national health insurance.
It is true, too, that the Ewing report made the mistake of implicitly ascribing many of the unnecessary deaths to mere lack of medical care, instead of stressing the social factors created by the nation's economic order which cause So much of the sickness that, in turn, produces such deaths. This laid the figures and arguments of the report open to criticism and harmed the cause of reforming the organization of medical care. But all this only underlines the need for more serious research on the causes of the tremendously high incidence of unnecessary death and the social and political problems posed by so much untreated sickness, suffering and disability.
The Ewing report bore the suspicious-sounding sub-title 'A Ten Year Program'; but all it did was to revive the mild, non-socialist legislative project of the New Deal period, which one Congress after another had voted down under the pressure of the rich and powerful 'lobbies' of organized medicine and the pharmaceutical and insurance business. It set goals for more medical manpower, more hospitals, more government subsidies, proposed a health insurance to be paid jointly out of employers' and workers' contributions and, in general, barely tried to keep pace with the established practices of other modern countries. But with all this it fell foul of the vested interests, for it would make for more competition between physicians, between hospitals, between a national health insurance and the high-priced private insurance schemes giving partial protection to about one-sixth of the people, which the A.M.A. has endorsed and virtually made its own. In short, while national health insurance would not establish `Uncle Sam, M.D.' as the 'dictator of American medicine', it would help provide the necessary treatment, through private physicians and hospitals for that majority of people who cannot pay the free market price.
Once again, the old fight came to a climax. The A.M.A. decided to create a S3 million 'war chest' for stronger lobbying in Washington against 'socialized medicine', for advertising its 'educational campaign', for distributing pamphlets in the physicians' and dentists' waiting rooms, hospitals and drug stores. It levied a $25 contribution on the 130,000-odd doctors whom it rules with an iron hand.
There were some signs of incipient revolt among A.M.A. members, a good part of whom see the crying need for measures such as the Government proposed, or even for more drastic ones. But subtle pressure, stigmatizing the professional ethics and patriotism of the dissidents, quickly put most potential rebels into their place. And while the public heard very little about the government's case but a great deal about that of the A.M.A. and remained apathetic, the doctors duly sent in their $2,$5, closed their mouths, went on delivering babies, cutting out appendices, treating sick hearts and lungs, and shrugged their shoulders when the day's work confirmed in six, seven or eight of every ten cases that most patients needed infinitely more material help than the most charitable physician could give them by way 0f reduced or cancelled fees or a free bottle of medicine.
Physicians have little choice but to conform to A.M.A. rules. For, even though the doctor 'who wishes to practise medicine does not have to join a county medical society and so become a member of the American Medical Association', the New York Times wrote on May 20, 1948, 'unless he does, his standing in his chosen profession is so low that the privileges of hospitals are likely to be denied him and that he will find it difficult both to qualify as a specialist and to be accepted as one'. This is what maintains the near-monopoly of the A.M.A. in American medicine.
The power of the A.M.A. is used more or less in the same way as near-monopoly is in other 'businesses', and most of its leaders and rank and file membership are no less honestly convinced than those of industry that they know best what the people need.
The U.S. Supreme Court, in a symptomatic case, ruled the A.M.A. guilty of 'conspiring to coerce practising physicians from accepting employment under Group Health Associates' (a co-operative, nonprofit organization for the voluntary insurance of government employees and others who tried to create for themselves a substitute for the lacking national health insurance); of 'conspiring to restrain practising physicians from consulting with Group Health doctors and ... from affording facilities for the care of patients of Group Health's physicians'. But this ruling had no practical effect.
Thurman Arnold, an outstanding lawyer who prosecuted this case for the Government when he was Assistant Attorney General, followed it up in 1948 in a letter to the chairman of the independent Committee for the Nation's Health. 'In spite of this decision', he wrote, 'organized medicine has continued to put obstacles in the way of the establishment and operation of non-profit voluntary medical care plans sponsored by other than medical societies. In seventeen states the state medical societies have obtained the passage of legislation which practically gives control over prepayment medical care plans to these societies and prevents farmers, industrial workers and other consumers from organizing under their own auspices. — . Organized medicine has utilized agreements, boycotts, blacklists, suspensions, and expulsions to prevent or impede physicians from participating in plans which would make medical services more widely available at less cost to patients. Under the code of ethics of the A.M.A., a county medical society may discipline or even expel a doctor who has entered into economic arrangements which the society considers "contrary to sound public policy". . . Thus the medical societies have assumed power over the practices of a profession, licensed by the state, and over the civil rights of American citizens.'
The retort to this letter in an editorial of Medical Economics, a magazine richly financed by advertisements of the drug industry and distributed free to physicians all over the nation, was as characteristic of the propaganda methods of organized medicine as were the former Assistant Attorney General's revelations about its monopoly policies. 'As a shrewd businessman', the magazine wrote, 'Thurman Arnold has also been quick to size up the possibilities in state medicine. He knows it would mean greater centralization of power in Washington and greater opportunities for those who helped to bring it about.'
The financing of publications like Medical Economics is by no means the only way in which the funds of business are used for the belowthe-belt fight of organized medicine against those who demand a socially more adequate practice of its profession. According to the reports 'lobbies' must file in Washington, more than a dozen of America's biggest pharmaceutical firms were the largest contributors to the $389,000 fund collected in 1946-7 by the N.P.C. (National Physician's Committee For The Extension of Medical Service), one of the A.M.A.'s propaganda arms.
The press normally is on excellent terms with the N.P.C.; for, apart from being a large advertiser, it induces other groups to use advertising space for anti- 'welfare state' campaigns. But in February 1948 the N.P.C. went too far in betraying its methods. It inserted a full-page advertisement in Editor and Publisher, the leading trade publication of the press, offering $3,000 worth of prizes to newspaper and magazine cartoonists for 'effective portrayal of the meaning and implications of "political distribution of health and care services in the United States".' Proof of actual publication in newspapers or magazines was made the condition for the entry of any cartoonist's work in the contest—a trick of the N.P.C. to give its propaganda many thousands of times the circulation that $3,000 could buy in advertisements. It is rare for Editor and Publisher to rap a big customer, yet in this case it did: `They offer rewards for doing a slanted job in newspapers and magazines, and it will be difficult for any cartoonist or his editor to deny charges of critics that they were bribed. . . .'
Red-baiting and racialism, too, have their place among the weapons of the well-organized fight against social progress in medicine. Compulsory health service is 'politically dangerous and Communist-inspired', Dr William B. Rawls said in October 1948 in his inaugural address as president of the Medical Society of the County of New York, the largest constituent body of the A.M.A. The pamphlet The Untold Story of State Medicine by Robert H. Williams denounced support for health insurance as 'Jewish and therefore Communist' and warned that measures like those proposed in the Ewing report were part of a sinister plot by Jewish, Negro and other minorities to make a Communist President of the United States by 1956.
Derision of state aid to health care abroad, particularly in Britain, has become a specialty of the propagandists of 'free enterprise' in medicine and other fields. One of the outstanding dignitaries of the Roman Catholic Church in America, Monsignor Fulton J. Sheen, did not think it beneath him to give this typical persiflage of Britain's `welfare state', according to the New York Times of August 28, 1949: `Socialism is that part of the economic system under which the state imposes a heavy tax on all the God-given teeth in order to supply everyone with state-given teeth, whether they are needed or not—and then rations everything that can be chewed.'
Deliberate lies in the form of cleverly disseminated anecdotes are standard practice in this struggle. Silly and seemingly harmless—like that about 'the English panel doctor who for years treated a man for jaundice until he found out by accident that the patient was a Chinese' —they sometimes prove effective in discrediting health insurance with the least informed of Americans.
This story, solemnly told in 1946 to a Senate Committee by a witness against the proposed health legislation, Dr Edward H. Ochsner of the Chicago Medical Society, is one of the favourites: A prominent Chicago physician visited a panel colleague in England to see how he handled the waiting-patients problem. As they stepped into the waiting room, the English doctor said to his forty-odd patients, 'will those of you who are troubled with a headache please stand'. Six stood up, while the doctor reached into his desk, took out six identical printed prescriptions, handed one to each of the six patients and dismissed them. Then, 'will those of you who are troubled with a cough, please stand'. Whereupon another group got up and the doctor followed the same procedure. The rest he took one by one into his private office for a few minutes each, until, within two hours, the office was empty of the forty-odd patients.
The secretary of the British Medical Association protested to the A.M.A. which gave much prominence to this 'true story'. But Dr Ochsner refused to divulge the name of the colleague whom he had quoted on this 'experience in England'. No wonder, for the man who initiated the tale may long be dead; he launched it on its eternal career more than a generation ago—about a German panel doctor—in order to discourage the introduction of the first health insurance programme in Britain in 1911.
The prospects for a modern health service are no better than the prospects for better nutrition, better housing, full employment, economic security and a more wholesome social climate—all of them basic conditions for an improvement in the people's health.
But there is another, even greater health problem in the United States: the trend to national hysteria, on the basis of deterioration of the psychological and mental health of many Americans, which the mass opinion industries foster and exploit.
`It is a fact that we have traits which make us susceptible to certain types of hysterical anxiety', Dr John A. P. Millet of Columbia University Medical Center told the New York Herald Tribune in November 1947: 'As a people, we have a deep fear of loss of material prosperity a curious association between wealth and goodness. To be wealthy means to be good. To be patriotic also means to be good. But to be seriously and actively concerned with the welfare of all the people, as opposed to that of one group, is not universally considered an essential aspect of patriotism. We know that we are the wealthiest and the most advanced nation, technically, in the world. Yet many Americans fear that we will, if we do not take repressive measures on a large scale, be destroyed by a h0stile power . . . proof that we have a basic and deep feeling of national insecurity. . . . With all our fine talk about democracy, we are secretly uncomfortable when we look at our unsolved areas of discrimination against Negroes and other minorities, of juvenile delinquency, of mistreatment of the insane, etc.'
Similar opinions were expressed in the report of President Truman's Special Citizens' Committee on Civil Rights, published shortly afterwards 'This pervasive gap between our aims and what we actually do is creating a kind of moral dry rot which eats away at the emotional bases of democratic beliefs', the committee warned Americans.
'We must act because the mental health of America is threatened by this gap', one of the authors of the report, Mrs Sadie T. M. Alexander, carried on this thought on October 8, 1948, at a forum reported by the New York Times. 'There are signs that the American people are becoming mentally ill . . . devel0p mental frustrations, bringing on fear and hate. . . . They result in investigations. Then we come along with witch hunts, and it will not be long before we will have purges, Gestapo and concentration camps.'
Whoever has lived in America during those years of frantic denunciation of anything that would not fit into the 'free enterprise' version of the American Way of Life, of red-baiting and noisy flag-waving, of silent frustration and cowardly coat-turning, must fear that she is right.
The disease is not confined to the political sphere where it is most manifest and most dangerous to the world. Its sources are deep in the minds of millions of people who, in the words of the report of the Federal Security Administrator, are suffering the peculiarly American `strains of competitive living, of financial insecurity, of . . . discriminatory practices and community rancors'.
`About one-seventeenth of the nation is psychotic, either confined in institutions or belonging in them', reported the New York Times of July 19, 1948. 'Eight million persons are suffering from some form of acute mental illness', according to the office of the U.S. Surgeon General. 'One out of every ten persons will spend some time of his life in a mental hospital, which means that 14 million persons now living will be hospitalized for mental illness at one time or another. . . . Then there are the neurotics, those who have not retreated quite so deeply into unreality. . . Conservative estimates by psychiatrists place this number between 1 o and 20 per cent of the population, excluding the psychotics. Statistics show that 5o per cent of the patients of general practitioners suffer from some form of mental illness,...1,846,000 of the 5,000,000 men rejected by the Army before induction were found to be suffering from neuropsychiatric disorders.'
'During World War II, 640,000 American soldiers cracked up from mental or emotional causes and became unfit to bear arms. . . . About 6o per cent of the breakdowns occurred before the men even were in combat', Associated Press reported from Fort Benning, Ga., on July 3, 1951, about an Army study of 'psycho cases'.
Alcoholism is another major problem. The Chicago Committee on Alcoholism estimated in March 1948 that there are '1,802,000 alcoholics employed in industry—many of them in top executive jobs'.
Mental illness, as a whole, is as great a threat in rural areas as in the cities, even though alcoholism, juvenile delinquency and sexual maladjustment are higher in urban centres. Some 3o per cent of all elementary school children in a county of Ohio State, according to a study of the Ohio Department of Public Welfare, show evidence of poor mental health.
Even the rising death toll from heart disease—so widely publicized in scare-creating articles by magazines that prosper on the hypochondriacal leanings of Americans the press helps to create—was found by New York specialists to correlate 'rather exactly with the rising level of general insecurity evidenced by individual feelings of anxiety ... the welter of irritation, bad temper and frank anger we live in. . .
The nation needs 21,000 qualified psychiatrists but has only 4,000, the National Committee for Mental Hygiene was told in December 1947. At least 3o million persons in the United States require some form of mental hygiene treatment, said the head of the guidance laboratory of Columbia University's Teachers College.
This is the physical and mental health of the most powerful nation on earth, upon whose performance and state of mind, more perhaps than upon anything else, the peace of the world depends.
It is by no means only a matter of more physicians and psychiatrists, more hospitals and cheaper and fuller medical care—but mainly, in the words of the Ewing report, one of 'relieving the people of the pressures of insecurity, discrimination, prejudices and the other social and economic inequities that exist'. In all these regards, however, America has made no progress in recent years. In fact, all these pressures have grown further, to a dangerous extent.
This is an indication of what Roosevelt meant when he warned in his Economic Bill of Rights message that 'without security at home—in this case, without the 'right for all to achieve and enjoy good health' —'there cannot be lasting peace in the world'.
The World The Dollar Built:
Death And The Dollar
The Other America
Oh, To Be Secure
Big Labor And Big Business
Global Chain Reaction
A Floor Under The Risks Of Peace
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