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CSU 31/2009: CHAPIN ON PUBLIC HEALTH IN THE US, ANDRIJA STAMPAR ON HEALTH POLITICS

Friday, 22nd of May 2009 Print

CSU 31/2009: CHAPIN ON PUBLIC HEALTH IN THE US, ANDRIJA STAMPAR ON HEALTH POLITICS
 
 
 
 1) NOTE FOR JOB SEEKERS
 
 Especially for spring graduates, here is a list of employment sites
 for some of the larger international agencies. Most NGOs have their
 own sites, some of which are listed with the Global Health Council.
 
 For the World Bank:
 
 http://web.worldbank.org/WBSITE/EXTERNAL/EXTHRJOBS/0,,menuPK:64262360~pagePK:64262398~piPK:64262365~theSitePK:1058433,00.html
 
 
 For UNICEF:
 
 http://www.unicef.org/about/employ/index.html
 
 For WHO:
 
 http://www.who.int/employment/en/
 
 
 For the US Agency for International Development:
 
 http://devex.com/signups/usaid?gclid=CM3GvN_ppJoCFRAhDQodYX8-9A
 
 
 For PATH:
 
 http://www.path.org/employment.php
 
 
 Global Health Council:
 
 http://www.globalhealth.org/jobs/index.php3?offset=0
 
 
 
 2) CHAPIN ON PUBLIC HEALTH IN THE U.S.
 
 For those interested in the development of public health in America,
 this article is a locus classicus.
 In his presidential address to the American Public Health Association
 in 1927, Charles Chapin looked over the period between the Civil War
 and World War I. He reviewed the progress and setbacks of public
 health during the Gilded Age, when the main burden of disease in the
 US was still from communicable diseases. Remarkably, his article shows
 that as late as the 1880s, Americans were still unaware of the
 demonstration by John Snow that cholera is a waterborne disease.
 
 Full text is at
 http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18012318
 
 
 SCIENCE IS PROGRESSIVE
 Science can never be a closed book. It is like a tree, ever growing,
 ever reaching new heights. Occasionally the lower branches, no longer
 giving nourishment to the tree, slough off. We should not be ashamed
 to change our methods; rather we should be ashamed never to do so. We
 should try new things, but should show common sense about it. The
 science which can point to its achievements against smallpox, malaria,
 yellow fever, diphtheria, typhoid and typhus fevers, tuberculosis and
 a score of other diseases, as well as to a rapid lengthening of human
 life, and especially to the saving of vast numbers of infants form
 early death, need not be ashamed to acknowledge that some experiments
 have failed; neither should it hesitate to admit that we are still
 merely picking up pebbles on the shore of the sea of knowledge, and
 that what is not known about maintaining and perfecting the health of
 mankind is far greater than what is known. The opportunities for
 discovery are as great as before the days of Harvey, Pasteur and
 Lister.
 
 
 3) ANDRIJA STAMPAR ON HEALTH POLITICS
 
 Andrija Stampar, the President of the first World Health Assembly,
 spent a life in public health, first in his native Yugoslavia, then in
 the larger forums of the League of Nations and the World Health
 Organization.
 
 
 
 Here is a sample of his writing, recently reprinted in the American
 Journal of Public Health.
 
 Good reading.
 
 BD
 
 
 
 On Health Politics
 
 
 
 Andrija Stampar, MD
 
 
 
 GOLDSCHEID POINTS OUT that we are living in a world blind to true
 value. We can see only sudden catastrophes and have lost the power of
 sensing hidden, continuous misery everywhere in present-day economic
 and social life. We have understanding only of inorganic capital and
 know nothing about human capital. In a wholly capitalist economy,
 where the loss of human life is considered only as a private loss for
 the family but as no economic loss for society, the economy of people
 becomes, of course, completely superfluous.... Today we abhor the
 contests that used to be held in Roman arenas but do not realize that
 today only the scene has changed, because masses of working people are
 getting ruined in factories which are often a worse place than ancient
 arenas....
 
 The entire life in present-day society is arranged in such a way that
 thousands and thousands of human beings are decaying for the sake of
 illusory success and even more illusory wealth. On the one hand, we
 have a great wealth of dead industrial products and are boasting of
 advances in our production, pointing out benefits deriving from it for
 public economy, and overlooking the fact that only the few profit by
 this economy; on the other hand, we do not see the legions of sick
 among craftsmen, factory workers, nor the mortality of children, nor
 tuberculosis, nor alcoholism among most working people: this means, on
 the one hand, wealth in dead things, and on the other, disease and
 death among the living. The whole national economy is enriched at the
 expense of people’s health....
 
 All our efforts made so far toward the promotion of public health
 have been considered as charity, as acts of humanity, and that is why
 the budget allotted for these efforts has been so small, for the
 understanding of charity can be found only among the few. Social
 politics and social hygiene have not shown any remarkable results
 either, because they have been conducted along the same lines; a
 turning point will occur only when health policy is looked upon as the
 most important part of national economy....
 
 All our efforts will fail until everybody enjoys the benefits of
 hygienic culture. It is in the economic leveling of society that the
 success of social hygiene lies. As early as 1848 Virchow said: "A
 sensible constitution is bound to guarantee real hygienic life to
 everybody."
 
 Examining the relation between disease and social conditions we are
 faced with a truth which indicts present-day hygienic culture very
 gravely: poverty is one of the most pronounced causes of disease....
 This is a dark side of present-day culture, this state of affairs
 should be abolished by the rebirth of the maxim according to which
 human life is the only true currency, the only true wealth. Away with
 the perilous anomaly that
 thousands of people go to rack and ruin by producing luxurious
 articles, under conditions most detrimental to their health, to
 provide ephemeral joy to the spoilt rich classes....
 
 The inadequacy of present-day health politics and social hygiene is
 perhaps not due to our not knowing all the fundamentals which govern
 them but to the fact that our sense of morality is not social but
 individual. Nowadays everything is considered from the standpoint of
 individual morality which in most cases is no morality at all but
 something quite opposed to it. These ethics are the result of bad
 management which aims at intensifying the economy of things without
 taking any account whatsoever of the economy of people.... There are a
 great many who only laugh at any emphasis on the ideals of justice and
 human rights. Social understanding is replaced by a merely individual
 one, which greatly obstructs the activity of national
 health politics.... At present we are going through a serious ethical
 crisis which will be overcome, and mankind will find the way toward
 ethical revival.... The health budget will not only comprise items
 relating to the help of the sick but will—to an undreamt-of extent—be
 used on preventive lines for the benefit of human material on which
 the nation’s attention will be focused. The war gave an impulse to all
 that, and developments in this direction cannot be stopped by any
 reaction....
 
 In this country there are about 27 deaths per 1000 inhabitants a
 year. If we compare our mortality rates with those in other countries,
 we can see that on the average twice as many people among us die as in
 the majority of other European countries. For the whole country this
 means a permanent annual loss of 175,000 human lives.... Mortality due
 to tuberculosis (45%) is ahead of all other countries; venereal
 diseases have long been endemic in many parts of this country and
 their spreading was considerably intensified by the war: alcoholism
 (14 liters of absolute alcohol per person) puts us in the third place
 in Europe.... This kind of health deficit can easily be seen from
 statistics, but the deficit in non-hygienic conditions in villages and
 towns, in workshops, factories and hospitals, in a complete hygienic
 illiteracy not only among the widest but also among absolutely all
 national strata—of this deficit we are not aware, because our eyes are
 blind, and our ears deaf to it....
 
 Health education has so far been carried out only by private
 initiative. The present time, however, calls for a more comprehensive
 participation of the state in this field of action.... Let the
 universities be the nurseries of health education, especially those
 preparing students for the professions that will bring them in contact
 with the people. Let future teachers acquaint themselves closely with
 the principles of school hygiene, future executive staffs with the
 principles of health policy, theologians with the hygiene of the
 parish, technicians within engineering and industrial hygiene, and
 farm workers with the principles of rural and food hygiene. Only by
 these methods can we educate people in a correct understanding of
 health needs and—what is even more valuable—in the ethical side of
 their duty to maintain health and prevent disease.
 
 It would be a mistake if health education were restricted to the four
 walls of the classroom. Health education should continue and be
 carried out most intensively outside schools.... Popular lectures,
 organization of special courses, exhibitions, publication of relevant
 literature, posters, the setting up of schools and associations with
 particular tasks, all these are powerful tools....
 
 Virchow, in his "Medical Reform," says: "Physicians are natural
 advocates of the poor, and social questions for the most part belong
 to their jurisdiction." Virchow’s opinion is still valid but has not
 been put in practice. Medical activities have begun to be drowned in
 purely materialistic waters, greatly resembling a business in which he
 who offers well and advertises still better gets most. Social spirit
 of any kind has disappeared from present-day medical activity, and
 physicians have become the slaves of capitalism, because there is no
 doubt that the benefits of medicine and hygiene are enjoyed only by
 those having much money. Most of our physicians still look upon
 medicine from the point of view of individual, and not from the point
 of view of social, practice....
 
 From the etiological point of view bad housing is one of the major
 causes of disease.... Building rules should be fully obeyed in the
 smallest village, because we should take care of the tiniest cottage
 just as thoroughly as of a town palace.... State housing control is a
 necessary legal regulation which sooner or later will have to be
 introduced.... The task of this control is to study housing
 conditions, to eliminate unfavorable factors, and to introduce
 improvements, especially when the economically weaker are involved....
 If we want to see our towns prosper in the near future, we must, at
 once, undertake all measures for securing the correct building of
 healthy houses, free from unscrupulous speculation....
 
 Workers’ health protection... calls in this country for the
 implementation of important social and medico-political measures.
 Certain restrictions are necessary regarding working time, because the
 human organism, however perfect it may be, cannot work like an
 ordinary machine; while the faults of an ordinary machine can be
 repaired, parts of the human organism recover very slowly or do not
 recover at all, and must not be exploited at will.
 
 The demands for an eight-hour working time should be strongly
 supported and justified from the medical point of view....
 
 The machine must not oust man from the workshop to make the capital
 invested in it pay higher dividends; it must help the worker, it must
 facilitate his work, and thus protect his health.... Technically
 facilitated and more advanced production must not benefit invested
 capital only, it should to a considerable extent be used for the
 improvement of working conditions –for the building of hygienic
 houses, the provision of good and cheap food, health education,
 etc.... The present time should give work its due, its dignity. The
 Government has allowed dead capital to drain it of its most valuable
 living capital—the human organism—for so many years, it must now allow
 the regeneration of this organism at the cost of dead capital.
 Social insurance is usually considered as part of the workers’
 question. Today it cannot remain within these restricted limits, it
 must develop into universal insurance.... In most countries, just as
 with us, the insurance scheme has existed only in the case of disease
 or accident. The present time requires general popular insurance in
 the case of disease, accident, unemployment, old age, infirmity, and
 poverty. We have to start tackling our social and health questions
 energetically and stop suffocating ourselves in pre-war mentality....
 
 Great material sacrifices necessary for the implementation of our
 health programs could be alleviated by special health taxes. This
 taxation system should be independent of general financial policy and
 the means obtained must be used for health investments, mostly
 preventive in character.
 
 
 
 1. A 2% tax on the direct tax to be paid by all tax-payers....
 
 2. A rate of 2% of the net profit of the industrial establishments
 employing more than 50 workers and legally bound to make its accounts
 public; those not legally bound to it should pay 3%, and those
 involving work injurious to human health should pay 5%.
 
 3. A rate of 5% of the net income of the firms engaged either in the
 production or sale of alcoholic drinks, unless they are taxed
 according to item 2, but if they should pay, in addition, the
 difference up to 5%.
 
 4. A rate of 5% on the prices fixed for the monopolized tobacco sales.
 
 5. A rate of 10% as the customs duty on luxurious objects.
 
 6. A rate of 10% for the monopolized sales of alcohol.
 
 7. A rate of 10% as a tax on the houses of those who live in these
 houses and have more than 5 rooms at their disposal, the rooms used
 for the carrying out of their profession being excluded....
 
 8. A rate of 10% as a tax on luxurious houses (villas, castles,
 etc.) which are only occasionally used as residences, for instances
 for hunting, excursions, holidays, etc.
 
 9. A rate of 5% of dividends obtained from shares held in various
 companies.
 
 10. A rate of 10% on liqueurs, rum, cognac, absinth and
 champagne....
 
 I have given an outline of the health program to be carried out in
 this country now in the post-war period. For the enormous and
 extremely urgent task we need not only a great many skilled experts
 but also even greater material sacrifices.... Physicians will not be
 allowed to remain in their hospitals, consulting rooms, and sterile
 offices—they will have to step into public life and fight for
 achieving an ideal—an appropriate health policy—and considering this
 policy as the most important part of general national political
 life....
 
 
 
 Footnotes
 
 
 
 Excerpted from Andrija Stampar. Jugoslavenska njiva. 1919;29–31:1–29.
 
 
 
 Republished in English in Grmek MD, ed. Serving the Cause of Public
 Health:Selected Papers of Andrija Stampar. Zagreb, Yugoslavia: Medical
 Faculty of the University of Zagreb; 1966:58–78.

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