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VOL. 34

APRIL 18, 1919

No. 16

INFLUENZA IN SOUTH AFRICA.

Over 40 per cent of its population affected with influenza in the four months during which the epidemic raged is the record reported by the Union of South Africa in an official Blue Book just received by the United States Public Health Service.

For the 6,115,212 population this means 2,616,805 cases of influenza, and of these, 139,471 were fatal—a case mortality rate of 5.32 per cent. This is certainly a severe visitation. The case mortality rate among the European stocks was less than half that among the non-Europeans, the respective rates being 2.57 and 5.90 per cent.

In South Africa persons in the third and fourth decades of life were particularly susceptible to attack by the disease, and the death rate was also greater in these age groups. A large number of instances were also noted where the disease resulted in miscarriages. Moreover, there was a high mortality among pregnant women.

The highest death rate from the disease was in the Cape Province, where out of every thousand of population there were 33.5 deaths from 'influenza and its complications. The rates for Orange Free State, Transvaal, and Natal were very much lower, being 18.21, 16.24, and 11.47, respectively.

HEALTH INSURANCE, THE MEDICAL PROFESSION, AND THE

PUBLIC HEALTH.

INCLUDING THE RESULTS OF A STUDY OF SICKNESS EXPECTANCY.! By B. S. WARREN, Assistant Surgeon General, and EDGAR SYDENSTRICKER, Public Health Statisti.

cian, United States Public Health Service.

The interest manifested by the medical profession and by health officials in the proposals for governmental health insurance in this country is as commendable as it is necessary. Any measure that may effect the quality and extent of medical service or that possesses possibilities in the prevention of disease is, it will be generally conceded, a proper subject of personal and professional concern to the physician, and a matter of vital consequence to public health administration. Health insurance-at least in some of the forms in which it has been suggested-without doubt is such a measure. In fundamental ways it proposes to modify some of the existing conditions of the practice of medicine. In a quite definite manner it promises Read at the annual meeting of the Medical and Chirurgical Faculty of Maryland at Baltimore, Apr.

2, 1917.

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to involve the social efficiency of all who are engaged in the work of conserving the health of individuals and of communities.

The physician and the health official, furthermore, perform a distinct service if they judge the various plans for health insurance by the criterion which these considerations suggest. It is proper, it is necessary, that certain questions be asked the proponents of any proposed form of governmental health insurance:

What effect will it have upon the professional work of the practicing physician and upon the quality of medical service?

In what ways does it afford the promise of more effective and extensive activities in disease prevention on the part of existing public health agencies?

Will the physician be enabled to do his work more efficiently, or will he have even greater handicaps than he already has? Will public health administration be helped or hindered ?

SICKNESS INSURANCE. For purposes of clearness it may be well first to state in a few words what health insurance, or, as it was formerly termed, "sickness insurance,

Sickness insurance is a method by which the economic loss caused by sickness is distributed among a group of persons. The distribution is effected by the payment of periodic

. premiums on the part of members of the group. In this way the cost of sickness arising from the stoppage of income, from fees of doctors, nurses, and hospitals, from expenditures for medicines, and the like, does not come as a sudden financial burden to the insured individual. This kind of insurance is now provided in the United States by many commercial companies and by thousands of fraternal orders and benefit associations of a wide variety of types, and is taken advantage of by a large proportion of those who are thrifty enough and financially able to pay the premiums. In the principal European countries sickness insurance of wage earners has been made a governmental function, but with certain fundamental differences from that form of sickness insurance which exists in this country. Among these differences are its extension to all wage earners upon a compulsory basis, the addition of medical and hospital service and certain other benefits to the cash payments to the sick, and the distribution of the cost of insurance not only among the insured, but also among the two other groups--employers and the public-who are considered responsible, in some degree, for the conditions which affect the health of the insured.

HEALTH INSURANCE.

The proposals for governmental “health insurance” in the United States not only adopt the principles just mentioned, but include additional features. Among these are an adequate meilical service for the

insured, and definite provisions for rendering the health-insurance system an aid to disease prevention. It has been proposed that the preventive force of governmental health insurance should not be limited to the financial relief during sickness, to the medical service afforded, and to the possible economic incentive to reduce sickness, but that it should be greatly increased by linking the health-insurance system to the existing public health agencies. In this sense, "sickness insurance,” it is believed, would become a real health measure. It would not be merely a variety of commercial or mutual insurance or another type of public relief, but a practicable method of improving and extending the present facilities for the prevention of disease.

From the viewpoint of the physician and of the public health official, the principal points which suggest themselves for the consideration of "health insurance" are as follows:

1. The sickness expectancy, i. e., the amount of sickness for which medical and surgical service must be provided.

2. Methods of providing adequate medical and surgical relief. 3. Methods of adequate prevention of sickness.

1. Sickness Expectancy.

Although in the absence of accurate statistics of morbidity in the United States it is impossible to arrive at accurate estimates of the amount of sickness occurring among wage earners, nevertheless considerable information concerning sickness expectancy may be obtained by a study of the experience of establishment sick benefit funds. Several estimates have been ventured, some of which have been based on extremely scanty material and some on more reliable data from surveys of actual sickness in industrial communities and from records of disability among employees of establishments. The wide difference in these estimates, from 6 to 9 days of sickness a year per wage earner, has served to call attention to the urgent need for accurate statistics.1

(a) Investigations concerning sickness expectancy.In the last two years the results of several “sickness surveys” or censuses have been published and have added materially to the very scanty American morbidity experience previously existing.

By the survey or census method the number of persons found sick on a given day in an enumerated population and recorded, affords the basis for computing the sick rate per 1,000 of the censused population as a whole or in sex, age, and other groups. In 1915–1917,

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"The American Association for Labor Legislation in 1911 estimated that the American wage earner loses on an average 8.5 days per year on account of sickness. The Federal Commission on Industrial Relations, in its staf report estimated from such records as were then available that the average loss of time from disabling sickness and nonindustrial accidents was about 9 days per year per wage earner. The Social InsurRace Commission of California in 1917 from a study of the records of American Beresit Association that were collected by the Federal Bureau of Labor a number of years previous and of such data as were available from similar records in California, estimated that the average loss of time per year per person was 6.5 days.

579,197 persons were censused in various localities by agents of the Metropolitan Life Insurance Co.; two censuses were made of certain districts in New York City by the department of health of that city; a survey was made of Dutchess County, N. Y., by the State charities aid association; and several surveys have been made in a number of textile villages in South Carolina by the United States Public Health Service. Without attempting to present and discuss in detail the variations in rates among persons of different sex, ages, occupations, localities, income, or other conditions, reference may be made to indicate morbidity rates and annual days of sickness per person among populations 15 years of age and over.

In the following table the experience from the above-mentioned sickness censuses is summarized. The results of the Dutchess County survey are not in a form that is comparable with the results of other surveys, and are omitted from the table. Table 1.---Cases of disabling sickness and rate per 1,000 of various populations 15 years

of age and over, and indicated average annual number of days of disabling sicknces po person.

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I Warren, B. S., and Sydenstrucker, Edgar: Statistics of Disability-A compilation of some of the data available in the United States Public Health Reports, Apr. 21, 1916.

2 See appendix B: Combined Sickness Experience of ihe Company's Surrers, 1915 to 1917, of the Vetropolitan 1 ise Insurance Co.'s publication, "Sickness Survey of Principal Cities in Penrsgivaria, and West Virginia,” by Lee K. Frankel, Ph. D., third rice president, and Louis I. Dublin, Ph. D., statistician. The "combined sickness experience referred to included the results of sickness surreys made in localities in Pennsylvania, West Virginia, and North Carolina, Kansas City (Mo.), Boston, Rochester, Trenton, sod Chelsen (New York City).

3 Wynne, Shirley Wilmott: Second Illness Census in the Experimental Health District. Monthly Bulls tin of the Departnient of Health of the city of New York, November, 1916.

Sydenstricker, Edgar, Wheeler, G. A., and Goldberger, Joseph: Disabling Sickness Among the Popola tion of Seven Cotton Mill Villages of South Carolina, in Relation to Income. Public Health Reports, Nor. 22, 1919.

With reference to the rates in Table 1 it should be noted that the rate for Government clerks is probably for a preferred occupation. The rate approximates quite closely that for office employees afforded in the experience of the Leipsig local sickness fund during 1887–1905.

The extremely high rate among the population of South Carolina textile villages, on the other hand, is probably due to a relatively low economic status.?

a

1 See Twenty-fourth Annual Report of the United States Commissioner of Labor, vol. 1, pp. 1281–1941.

2 For a discussion of the sickness rate : mong persons of different family income in the population censused see Public Health Reports for Nov. 22, 1918. Sup. cit.

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