Social  Aspects of Health

by Ralph  E.  Pumphrey,  Professor George Warren Brown  School of Social Work Washington University, St. Louis, Missouri

Social Aspects of Health, 1873 – 1973

Health has been an area of concern in the deliberations of the National Conference throughout  its history.  The topics discussed have reflected in a general way the broaden­ing conceptions  of health and ways to promote it which have been abroad during the past century.  And  yet  it  was only occasionally  that  health  matters  seemed to be in priority positions, or that crucial issues were being debated.

There  were probably  many  reasons for this. The immediate  occupational  concerns of most  participants  were  elsewhere.  The  social implications  of ill-health  were long sub­sumed  under  the  general heading of “pauperism,” a more or less helpless condition  for which the least expensive care was to be sought. When the importance  of social factors in the incidence  and  recovery  from  illness drew  the  attention of Richard  Cabot  and  Ida Cannon,  their  basic  relationship  of  physician  and  nurse  meant  that  social work  was subordinate  to medical  work.  Over the years medical  social  work  discussions became heavily focused on work with individuals, a tendency encouraged by Freudian concepts emphasizing internal and familial rather than more broadly social influences. Exciting environmental  studies in which early  medical social workers took leading parts became the preserve of the public health movement.

Physicians frequently  have had important parts in National Conferences, but seldom as physicians and almost never as bridging persons between medicine and social welfare. For instance,  in the 1932 Conference  Dr. ‘Richard  Cabot gave the presidential address and Dr. Ray Lyman Wilbur was one of the principal speakers. However, Dr. Cabot, who was somewhat  out  of step with some of his medical colleagues, spoke more as the founder  of medical social work  than as a representative  of the medical profession, while Dr. Wilbur, past president  of the American Medical Association, formerly  dean of one of the leading medical schools in the country, and at the time chairman of the precedent-setting  Com­mittee  on the Costs of Medical Care, spoke in his capacity as Secretary of the Interior,  a political appointment under President Hoover, and only mentioned medical concerns in passing in his address on the United States Children’s Bureau.

Such limited participation may indicate that the often-stated  disdain of the medical profession  for  social work  and  the  manifestly  superior  political  clout  of the American Medical Association  could not be modified by isolated speeches and discussions at annual meetings. To attempt  serious discussion of health  policies must have seemed an exercise in frustration.

Keeping in mind  this peripheral involvement in the social issues related to health, it is interesting  to look at Conference  programming at four different  periods to see the changing emphases revealed in the Indexes.

During the first decade of the Conference  the care and treatment  of the insane was the principal  health  topic,  not surprisingly in view of the responsibilities for state and local institutions carried by most of the delegates. Such attention as was given to other “medi­cal charities”  seems to have been dominated  by a fear that  they were being “abused” by persons  who  were  not  eligible for  the  help given and reflected  a narrow conception  of responsibility and a lack of appreciation  of the financial burden of illness.

A  generation  later,  during  the  Progressive era immediately  preceding World War I, insanity,   together  with  feeblemindedness, was still  a  major  concern,  though  the  new mental  hygiene  movement  had  injected  a  somewhat  more  positive  tone  into  the  discussion. Equal or greater attention went  to public health  activities, both  preventive and remedial, although  the early push for health insurance had not yet taken shape following the  success  of  the  movement   for  workmen’s compensation   legislation.  Such  major scourges as tuberculosis  and syphillis, and the physical and economic  handicaps coming from  industrial  accidents  and  disease were discussed extensively.  Medical social service took  its  place as a recognized aspect of medical treatment. Considerable negative attention  was directed  towards  the evils associated with commercial recreation (prostitution, venereal disease, etc.) which was partially balanced by attention to the salutary effects of outdoor  recreation.

As another  generation  passed, the Great Depression and World War II dominated  the Conference  agenda  for  a. decade  and  a half.  Health interests  in Conference  programs reflected  the  report  of  the Committee  on the Costs of Medical Care, the fight over the inclusion of a health  insurance  title  in  the  Social Security  Act,  and  the  succession  of Wagner-Murray-Dingell bills. In the minds of the promoters of these measures, they were closely related to public health  work, and it was public health and other medical services which  were most  prominent  in conference  programs. Positive mental  hygiene programs tied in with  this  approach.  Handicaps and specific diseases were less prominent  than in the past.

In the most recent  period, since 1965, Conference interest  in health  has shown three model areas of emphasis – on  mental  illness and  retardation, on  alcoholism  and drug abuse, and on various sex-related subjects such as illegitimacy, family planning, abortion, and  venereal disease. In  all of these and many other  places in the programs the role of social work in facilitating adjustment  and recovery from illness was played up extensively. Abused  children,  the  chronically  ill and  the  handicapped  received scattering  attention along with new developments in medical care, preventive medicine and health insurance, while the world population  problem was treated at one isolated session.

In sum, while participants  pay more attention at the Conference  now than a century ago to prevention  and remedial treatment, they  are still focused on the problems created by disease and handicaps. For the most part we react to that which we find wrong. In the future   might  we  assume  a  more  central  position  and  ask:  “Are  our  standards  good enough? How can we improve them?”

A Spectrum of Social Concerns About Health

What should  we be concerned  about  today  and in  the  next  decade? There  is a be­wildering range of  possible topics which might be brought  up. Some grouping of them may help to focus attention.

Care of the Ill and Incapacitated. In American culture this residual function  is manda­tory. Basically citizens have always regarded this as a responsibility  of family and neigh­bors. From earliest colonial times, however, such voluntary activities have been supported and supplemented  by community  effort.  As the number of persons and institutions with specialized expertise  has increased, they have tended to supplant voluntary efforts, often to  the  relief, but  sometimes  to  the  distress, of  the  would-be helpers. Two intervening forces can be mentioned here.

Professional specialization has all but ruled out  the casual helper. Nursing as a profes­sion got  its start  in  this country  about  a century  ago. Specialization  according  to the illness, the kind of patient  dealt with, and the function  performed  has brought not only obstetric,  psychiatric  and geriatric nurses, but also nurses aides, licensed  practical nurses, registered nurses, visiting nurses and a variety of highly skilled dual professionals such as nurse-anesthetists.  Comparable  degrees  of  specialization  can  be  found  in  most  other fields.

Increasing  technology  has also entered  in. The  search for analagesics spawned phar­macy as a profession and as an industry.  The industry has expanded into the production on a giant scale of the bandages and equipment  which are used in the care of the ill and injured. Two decades ago the manager of a pharmaceutical factory was heard to comment that  all the  bandages which  were produced  by all the volunteer  efforts  in the country during a full year of World War II could have been produced in his factory  in a single day. The care of illness has come to be BIG business, not the least part of which is institutional care. We have had hospitals for centuries. During the past several decades their increasing numbers,  size, and complexity  whether  under voluntary  or governmental auspices, have made them major economic entities. Now institutionalized nursing care has burgeoned to the point of becoming another substantial  business as well as philanthropic  activity.

So long as illness and  injury  occur,  care of  the  victim  can  be expected  to  have an overriding  claim  on  individual  and  social  resources.  The  golden rule  takes  on  a very personal  meaning in this context  and they  are hard-hearted  indeed who deny care. Fur­thermore,  it provides employment  for thousands of wage earners which might be extend­ ed to thousands more. Yet we have long since ceased to think that just any kind of care is all that is needed.

Social welfare’s concerns in this area are pretty  well defined in several directions:

a.  The quality  of care provided – are the facilities, staff, food, and amenities kept up to standards everywhere and not merely in showcase institutions?

b. The distribution  of care – are some persons in need of care neglected while others are cared for in luxury?

c. The development  of necessary manpower  – does this kind of personal care afford an  opportunity for  the  employment   of  people who are presently  marginal in the labor market? Can such employment  be both socially useful and personally   satisfying?

d. Are we keeping a proper  balance between care on the one hand and the prevention of illness and handicaps on the other? Are we adequately  providing for the financial needs of individuals and families so that  the drain caused by care will not bring on secondary breakdowns?

Care of Illness. Alongside care there has always been the goal of curing the sick. Almost universally healers, medicine  men  and  doctors  have held respected,  not to say mystical, authority   among  their  fellows..The  search for causes and cures has led to drawing with increasing .self-assurance  on  the  whole  range of  natural  and physical sciences and  their derived applications,  from physiology and chemistry  to computers and laser beams, to intervene  against challenges to  the health of the individual which in the not  too distant past would have been fatal. With each new invention  or discovery, medicine and surgery push further  back the threats to survival to which mankind has been subject.

This phenomenal development depends not merely on specialized knowledge but, even more  than in the case of care, on the availability of tremendously  complex  technology. Typically  this is to  be found in hospitals. While patients  may obtain  some of the more common  technological services such as X-rays, electrocardiographs and various laboratory tests  from  specialized  service groups  in  the  community, or even from individual physi­cians, the more complicated diagnostic processes and nearly all surgical procedures require facilities and equipment which are made available by society  through  capital investment in hospitals.

Quite  apart  from  the  hospitals  and other  service arrangements  themselves, this com­plex of curative  efforts  is the  base for  major economic  activities. Research for  the development and production  of new “wonder  drugs” draws on important  scientific know­ ledge and supports  both  professionals and  the  industries by which they  are employed. Similarly, the wide range of equipment utilized draws on the engineering professions and supports important segments of industry.

As social welfare contemplates  this necessary function in a never-ending effort, it may wish to focus on such topics as these:

a. As care and cure become commercialized, what protections  does the public have against  their  misdirection?  A  wide  range of explorations  is suggested by recent allegations that  over-commercialization of legitimate medications is encouraging a “drug culture.”

b. How accessible is medical technology to those who need it? Do the development of air ambulance systems to transport  accident victims to hospitals suggest the need for fresh looks at the problem of distribution and accessibility of medical services?

c. Are we keeping a proper balance between the curing function and other parts of the spectrum?

Alleviation of Financial Stress. It has long been pointed out that illness is costly to the victim in two ways. There is the  direct cost involved in securing medical care, and the indirect cost in lost wages if the victim or members of his family have to stay away from work. There are more remote indirect costs to the employer in lost productive capacity; to merchants and others in reduced purchasing capacity; and to the public sector in the loss of tax revenues. Such costs are relatively minor and bearable in many illnesses where the family income is reasonably secure, but may become disastrous for the individual and troublesome for the community in so-called “catastrophic illness.”

During the  past sixty years  in this country,  much has been done  to deal with this complex of problems: The devastating losses by victims of industrial accidents were reduced  by  the  introduction   of  workmen’s  compensation  – later  extended  to cover occupational  illnesses. Wage loss insurance  has become available through  commercial channels  but  to  date  meets  only  a  fraction  of  actual losses. Other provisions for the financial needs of the disabled have been made in the form of Aid to the Permanently and Totally Disabled and Disability Insurance. Both were approached with caution, not to say reluctance, by Congress which demonstrated  an almost pathological fear of malingering. Eligibility requirements  have .been rigid and  benefits limited,  but they represent major advances in one aspect of provision during the past quarter century.

Additional measures have been projected and debated in what has come to be a major area of unfinished social and political business. As we move into a second century of the National Conference, health minded persons may well raise the same questions that have been raised in one form or another during half of the century which is now ending:

a.  Do the existing methods  of dealing with  the financial stress of illness reach the persons they are designed to help and, taken together, do they provide adequate coverage for the total population?

b. Are the benefits under  these programs sufficient to meet the needs of those cover­ed?

c.  Do  other  income  maintenance  programs provide  sufficient  financial support  to enable those who are dependent on them to maintain their health?

d. How  can  the  cost  of  any  increased  benefits  be  met  without  bankrupting  the country?

Reduction of the volume of illness. The discovery of causes for illnesses, which permits the formulation  of curative measures, carries the implication that, in some cases at least, the causes may be removed before an illness occurs at all. Gross preventive measures may even  be  undertaken   before  exact  causes ate  known.  The  importance  of  a pure  water supply  and  other  sanitary  measures  was  recognized long before  the  specific cause of typhoid  fever was determined.  Nevertheless, it has been after specific causes have been discovered  and  steps  have been   taken  to  intercept   or  destroy them  that  phenomenal successes have occurred. Smallpox, yellow fever and tuberculosis are classic examples of this approach.

It is a fact of some importance  that both the cure of illness and its prevention became broad areas of specialization as the practice of medicine and public health work, respectively, with relatively little interchange of personnel and with a considerable amount  of misunderstanding  and suspicion attached  to those who did seek to tie the two together. As various disease entities for which environmental control measures were most ap­propriate  were overcome in large measure the public health  people began to emphasize early diagnosis and treatment  of illness as important  factors in improving the general level of health. They sought ways in which the most advanced medical knowledge and services could  be made available to  all people,  not  merely a privileged few. In  so doing,  they proposed changes in the system of delivery of curative medical services.

As a  result  of  their  efforts   the  neglected  segment of  the  population  between  the “haves”  who could pay for whatever medical care was needed and the “have nots” who received free care because they could afford  to pay nothing  was somewhat better served by  making clinical and hospital  services available at reduced rates for those who could afford  to  pay something.  Also, for increasing numbers of people it became possible to distribute  the  direct  costs  of illness through  a variety of pre-payment or post-payment plans and medical expense insurance, including medicare for the elderly, thus improving · their access to medical care.

These and other  developments and proposals distressed many and enraged some medi­cal practitioners  with  the result that  rational discussion of the proposals became virtually impossible. During  the  past half century  those devoted to medical practice have exerted pressures to confine public health efforts to the maintenance of the kinds of sanitary, epidemiological and other  preventive measures which had already been demonstrated  and to the development  of mass health education programs, specially in the realm of personal hygiene, separated from the direct practice of medicine and the treatment of illness. Meantime, in the practice of medicine an important  place is now given to preventive work with  patients  through  periodical health examinations  and health  consultations.  Some of the  newer  experimental  community   health  programs  give further   indication  that  the long-standing cleavage between the two fields is being eased.

It should be noted  that  while public health has not been permitted  to move far into the direct treatment  of illness, by its involvement in such activities as supervision of water supply, in the enforcement  of regulations to insure pure food supplies and the installation and operation  of sewage and other  environmental  disposal and protection  systems it is involved in major  public  programs and expenditures  which, in turn,  contribute  both  to the tax burden and to the economy. It depends not  only on staff with medical training, but also on people with a wide variety of professional or occupational  training, including engineers, biological and physiological scientists, nurses, social workers, and statisticians.

The current  rash of proposals for new delivery systems has become entangled as others before them in issues related to methods of payment for service. At one pole are individu­ally billed and paid fees for  service. At another  are services provided by salaried profes­sionals with no form of individualized fees. Both extremes are found readily in the United States today. Between them are a wide variety of plans and proposals designed to ac­commodate  traditional  concepts  of doctor-patient relationships  to modern economic and social realities.  Labels are inexact  and confusing,  but  many insurance  plans serve essen­tially  as financial  intermediaries   between  the  patient  and  the  service deliverer. Others, whether  called “insurance” or not,  include both a prepayment  arrangement  and a service delivery component, including in some cases, payment for services outside the system, for instance for  the use of a hospital. The range of proposals currently  before Congress raises the  possibility  that  four  decades after  the first serious consideration  and a decade after the passage of the first aspect, Medicare, some form of general health insurance will come into being on a national, compulsory  basis.

Obviously,  the  professional,  political  and  economic  problems  centering  in  this  area continue  to  produce  some of the most hotly  debated  issues of our  time. The effects  of their  resolution  will be felt  by the entire  society,  and will have repercussions on a wide variety of other  problems and services. It follows that  all of social welfare has a stake in the ramifications as well as the central issues in such questions as:

a.  Are there  ways to  organize  the  delivery  of health  services which will insure that medical care and treatment will be accessible to every person who needs them?

b. What are  the  means  of  financing  the  delivery  of  health  services which will most effectively support  the accessibility of the services to all?

c. What are the legitimate  professional and economic considerations which must be recognized in the arrangements for delivery and financing of health services?

d. Are excessive professional  or economic  pretensions  and pressures interfering  with maximum  use of all the available, appropriate  resources which would contribute to reducing the volume of illness and incapacity?

e.  Are we giving an appropriate  amount  of attention and support  to this segment of the spectrum of health concerns?

Adaptation  to  conditions imposed by illness. The  victim  of illness is dependent  on other  persons  to  provide him the services needed for cure. He and his family, however, must  make  most  of  the  adjustments   to  the  new conditions  which  are forced  on him during and after  his incapacity.  His freedom  of movement  is limited; he may not engage in certain  activities; he may have to fore go short  range, or even long range, goals. Not to do  so  would  involve  risks  whose  import   he  needs  to  understand. His condition  may inspire a variety of reactions·among  relatives, friends, and associates. Some conditions  are temporary; some  can be  overcome  or  compensated  for; still  others  are permanent  and essentially irreversible.

Around  these conditions  and reactions have developed a network  of services more or less closely related to medicine. The manufacture  of appliances, from wheel chairs to prostheses  to  pacemakers,  is  perhaps  a minor  but  nevertheless  significant  part  of  the general economy.  The  training and retraining  of individuals in new or lost skills is impor­tant not only in hospitals, rehabilitation  centers and sheltered workshops, but in industry . But many  people also need help in observing prescribed  medical regimes, in evaluating a situation  and accepting  in a realistic way the limitations  which it imposes, and in arriving at a constructive  attitude in which to move forward. The professional roles of both nurses and  medical social workers  have been  shaped  in large measure by the expectation that they  will carry primary responsibilities in this general area. Such services are of great importance  to  the individual and to society. There is a crying need for more of them in our present state of ill health.

Those interested  in the social aspects of health and the health aspects of social welfare may well raise such questions as:

a. What changes in demand for this kind of service may be expected with developing programs aimed at reducing the volume of illness? Specifically, does the developing concept  of health maintenance  organizations (HMOs) include this aspect of health services, or are they exclusively medical?

b. What changes in professional education are needed to keep pace with developments in  this aspect  of  the health  field? Is there need for cooperative programs of edu­cation  between nursing, social work, medicine and perhaps other professions and/or occupations to secure increased effectiveness of services?

c.  As the level of health improves, should we look forward  to much of the need for this type of services being related to the aging population,  and gear our educational and vocational counseling efforts in that direction?

d. To  what  extent  is this type of service especially needed in relation to health pro­ grams  in poverty areas where use of modern medical resources has heretofore  been minimal?  Orchestration of  Efforts. To  a  limited  degree we  have  developed  multifunctional delivery units for some of the steps so far outlined. In particular, hospitals provide care, cure, and, in varying degrees, adaptive services. The traditional pattern, however, has been to develop activities singly, apparently completely independent  of, or even in competition with, each  other.  The  overall result has been  that  we have inherited  a hodge-podge of activities and programs which we euphemistically call a “health  delivery system.”

From  the  standpoint   of  the  recipient  of  service, the  effectiveness varies with  the circumstances.  Sometimes  it  is judged to  be good  to  excellent.  In  many  instances the outcome  is less than desired but is accepted  by the victim and society with the fatalistic judgment that it is the best that can be expected under the circumstances. Some apparent stupidities, such as calling an ambulance to transport  the dying victim of an auto accident

26 blocks from the threshold of a general hospital to another hospital, bring the “system” into disrepute. In other cases, a few of which receive feature treatment in the news media, the gap between  that  which has been established as good procedure (as in kidney  trans­ plants  or cardiac seizures) and the ability of the system to deliver that procedure  to all who would  benefit  from  it  stands  as a challenge to  the  prevailing ethical standards in society.                                          ·

Rationalization  of this complex structure  has been the subject of increasing attention and effort  over the past two generations. The concept  of the hospital as the nexus in a network  of medical, rehabilitative  and  preventive services was being discussed prior to World War I. It received  official  impetus  in  the  Hill-Burton Act  and in  the  National Mental Health  Act  at  the end of World War II. Flowing from these have come regional hospital  planning  and  programming  for  comprehensive community  health  and  mental health services.

If   enacted,  it seems  probable   that   national   health   insurance   legislation   will substantially encourage the development of comprehensive health maintenance services, including not only care and cure, but also rehabilitation  and, to an extent  not heretofore seen, prevention  on  both  the individual and community  basis. It will thus promote  the corning together  of  the “practice  of medicine” and public health  work. Taken  together with the  more vigorous supervision of the planning of facilities which is now going on, these developments may substantially enhance the orchestration  of activities in the health field, although it is hard to envision any sudden transformation.

This brings to the fore the need for continuing review of the rights and responsibilities of  both  voluntary  and  governmental  organizations.  What is the  role  of  the local unit, whether governmental  or voluntary,  in the shaping of the implementation of broad pol­icies set at the state,  national,  or even international  level? What degrees of governmental stimulus, prodding or compulsion  will be required  to achieve broad general goals, and at what levels of government? What can voluntarism contribute  to the provision of services, to the formulation  of policy, to the building of public understanding?

The  ongoing discussion of such issues as these  need  not  be specifically directed  to health  topics to contribute  significantly to the furtherance  of the social aspects of health.

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Ralph E. Pumphrey is Professor of Social Work at the George Warren Brown School of Social Work, Washington University. He received his AB from  Miami University, Oxford,  Ohio (1928),  Ph.D. in History  from  Yale University (1934),  and  graduated  from  the  New York School of Social Work (1940). His practice experience includes: Exec. Sec., Council of Social Agencies, Syracuse, New York (1944-1946);  Exec, Dir., Health and Welfare Council, Indianapolis, Indiana (1946-1951),  Field re­presentative and public relations director, United Community Defense Services (1951-1956).  He was Associate Professor of Social Work at New York University (1956-1959)  before going to Washington University. He has served as consultant  to  the  Upper Great Plains Committee on Social Work Edu­cation and as a member of the Task Force on Exits from Poverty appointed by the Secretary of HEW. With Muriel W. Pumphrey, he edited The Heritage of American Social Work (1961) and he is currently preparing a biography of Michael M. Davis, pioneer social worker and medical economist, who had answers for most present-day questions about social aspects of health decades ago.