Popular Science Monthly/Volume 25/September 1884/National Health and Work
By Sir JAMES PAGET, F. R. S.
IT was very difficult to select, from the vast number of subjects relating to health and to education, one of which I could fitly speak to-day. On general education I could not venture to speak; and, believing that I should have to address a large and various audience, I thought it would be best to choose a subject by which I might urge one of the chief objects of this Exhibition, and one which I know that you, sir, have always had in view, namely, that the public themselves should consider, much more than they do, the utility and the means of maintaining their own health. I have, therefore, chosen the relation between the national health and work; especially as it may be shown in a few of the many examples of the quantity of work which is lost to the nation, either through sickness or through deaths occurring before the close of what may fairly be reckoned as the working-time of life. I think it may be made clear that this loss is so great, that the consideration of it should add largely to the motives by which all people may be urged to the remedy of whatever unwholesome conditions they may live in. It is a subject which is often in the minds of the real students of the public health, but the public itself is far too little occupied with it.
I shall speak only of national health. In consideration of his own self, a man may be deemed healthy who lives idle, comfortably, and long; who enjoys every day of his life, and satisfies every natural appetite without consequent distress. And when such a one dies of old age, with a timely, uniform, and painless decay of every part, he may be deemed to have been completely healthy. And yet it is possible that he may have enjoyed his own health in the midst of a poor, unhealthy, and unhappy nation, to which he has done no good whatever.
If we could find a nation composed of people such as this man, we might be bound to speak of them as healthy; but we should be right in calling the whole nation utterly unsound, and might safely prophesy its complete stagnation, or its quick decline and fall.
It is not health such as this—idle, selfish, unproductive—that we want to promote either in the individual or in the multitude. Comfortable idleness, such as that of some vagrants and fine gentlemen, is a despicable result of good health; it is what no thorough man would ever wish for. In view of the national health and welfare, the pattern healthy man is one who lives long and vigorously; who in every part of his life, wherever and whatever it may be, does the largest amount of the best work that he can, and, when he dies, leaves healthy offspring. And we may regard that as the healthiest nation which produces, for the longest time, and in proportion to its population, the largest number of such men as this, and which, in proportion to its natural and accumulated resources, can show the largest amount and greatest variety of good work.
Here let me insert, as an interpretation clause, that in all this and what is to follow the word "man" means also "woman," and "he" means also "she"; and that, when I speak of work, I mean not only manual or other muscular work, but work of whatever kind that can be regarded as a healthy part of the whole economy of the national life. And I shall take it for granted that a large portion of all national welfare is dependent on the work which the population can constantly be doing; or, if I may so express it, that the greater part of the national wealth is the income from the work which is the outcome of the national health.
It is a common expression that we do not know the value of a thing till we have lost it; and this may be applied to the losses of work which are due to losses of national health. There are very few cases in which these can be estimated with any appearance of accuracy; but I am helped to the best within our present reach by Mr. Sutton, the Actuary to the Registry of Friendly Societies. In his office are the returns, for many years past, of the sickness and mortality among the members of a very large number of these societies; and, among other things, there is recorded the number of days which each member, when "off work" on account of sickness, receives money from his society. Hence Mr. Sutton can estimate, and this he has been so good as to do for me, the average number of days' sickness and consequent loss of work among several hundred thousands of the workmen and others who are members of these societies. From the entire mass of these returns, he deduces that the average number of days' sickness, per member per annum, is very nearly one and a half week; and this agrees, generally, with the estimates made in other societies by Mr. Neison and others. But the averages thus obtained include the cases of members of all ages, and among them many cases of chronic sickness and inability to work during old age. In order, therefore, to get a better idea of the actual annual loss of work through sickness, he has calculated the average annual number of days' sickness of each person during what may be deemed the normal working-time of life; that is, between fifteen and sixty-five years of age. This he has done among the members of the large group of friendly societies known as the Manchester Unity of Odd-Fellows; and then, on the fair assumption that the rates of sickness of the whole population during the working years of life would not be far different, he has calculated the following tables, showing the average annual rates of sickness of each person enumerated in the census of 1881, as living between the ages of fifteen and sixty-five:
Briefly, it appears from these tables that the average time of sickness among males during the working years is 1·314 weeks—that is, a small fraction more than nine days in each year—and that among females it is a small fraction more. The result is, that among males there is a loss of 9,692,505 weeks' work in every year, and among females a loss of 10,592,761 weeks. Thus we may believe that our whole population between fifteen and sixty-five years old do, in each year, 20,000,000 weeks' work less than they might do if it were not for sickness. The estimate is so large that it must, on first thoughts, seem improbable; but on fair consideration I believe it will not seem so. For the members of the Manchester Unity who are in the working-time of life, the reckoning is certainly true, and it is founded on the experience of between 300,000 and 400,000 members. In respect of health they may represent the whole population, at least, as well as any group that could be taken. They are not very strictly selected—they are not picked lives; yet they are such as are able, when they are in health, to earn good wages or good salaries, and, as their prudence in joining this association shows, they are comparatively thrifty and careful persons. They do not, at all events, include many of the habitual drunkards, the cripples or utterly invalids, or those who, through natural feebleness or early disease, or mere profligacy, can not earn enough to become members or maintain themselves in membership. Neither do they include many of the insane, or imbecile and idiotic, of whom there are, in our population, nearly 70,000, doing no work, and losing not less than 3,500,000 weeks' work in the year.
It would be tedious to tell the grounds on which the estimate may be deemed too high, for just as many and as good could be told on which it might be deemed too low. And it is rather more than confirmed by some estimates of the annual sickness in other and very different groups of persons.
In the army, at home, the average number of days' sickness in each year is, for each soldier, about seventeen; and, as the number of the troops in the United Kingdom is more than 80,000, we have here a loss of about 200,000 weeks' service in each year.
In the navy, on the home stations, the average number of days' sickness in each year has been in the last five years for each man nearly sixteen; so that for the total of about 20,000 men there is a loss of 45,000 weeks' service in each year.
The amount of sickness in the services thus appears much higher than in the friendly societies. This is due, in great part, to the fact that a soldier or a sailor is often put off duty a day or two for much less illness than that for which a civilian would "go on his club." Still, the one estimate may confirm the other; for the sickness in the army and navy is that of picked men, who were selected for the services as being of sound constitution, and who are in what should be the best working years of life: and, if it includes many cases of sickness for only a day or two, it excludes nearly all cases of more than a few months, such as make up a heavy proportion of the average sickness in the friendly societies and in the general population.
And I may add that the estimate from these societies, that nine days in the year may justly be thought a fair estimate of the working-time lost by sickness, is confirmed by the records of sickness among the 10,000 members of the metropolitan police force; for among these, including cases of long illness such as are also in the societies, the average is more than nine days in the year.
I think, then, that we can not escape from the reasons to believe that we lose in England and Wales, every year, in consequence of sickness, 20,000,000 weeks' work; or, say, as much work as 20,000,000 healthy people would do in a week.
The number is not easily grasped by the mind. It is equal to about one-fortieth part of the work done in each year by the whole population between fifteen and sixty-five years old. Or, try to think of it in money. Rather more than half of it is lost by those whom the Registrar-General names the domestic, the agricultural, and the industrial classes. These are more than 7,500,000 in number, and they lose about 11,000,000 weeks; say, for easy reckoning, at £1 a week; and here is a loss of £11,000,000 sterling from what should be the annual wealth of the country. For the other classes, who are estimated as losing the other 9,000,000 weeks' work, it would be hard and unfair to make a guess in any known coin; for these include our great merchants, our judges and lawyers, and medical men, our statesmen and chief legislators; they include our poets and writers of all kinds, musicians, painters, and philosophers; and our princes, who certainly do more for the wealth and welfare of the country than can be told in money.
Before I speak of any other losses of work or of wealth due to sickness, permit me, as in parentheses, to point out to you how very imperfectly these losses are told, or even suggested by our bills of mortality. These, on which almost alone we have to rely for knowing the national health—these tell the losses of life, and more than misery enough they tell of; but to estimate rightly the misery of sickness, and the losses of all but life that are due to it, we need a far more complete record than these can give.
Take, for example, such a disease as typhoid fever—that which Mr. Huxley has rightly called the scourge and the disgrace of our country. It has of late destroyed, in England and Wales, among persons in the working-time of life, nearly 4,000 in the year. Its mortality is about fifteen per cent, so that, if in any year 4,000 die of it, about 23,000 recover from it. Of these, the average length of illness is, on the authority of Dr. Broadbent, about ten weeks. Here, therefore, from one disease alone, and that preventable, we have an annual loss of 230,000 weeks' work, without reckoning what is lost with those who die. And the same may be said of nearly all the diseases that are most prominent in the bills of mortality. The record of deaths, sad as it is, tells but a small part of the losses of happiness and welfare that are due to sickness. It is as if in a great war we should have a regular return of the numbers killed, but none of the numbers wounded, though these, more than the killed, may determine the issue of the war.
Let me now tell of another loss of work and of money through sickness and early death. In all the estimates I have yet referred to, no account is taken of those who are ill or die before they are fifteen years old. They are not reckoned as in the working-time of life, though in some classes many thousands of them are. (In the domestic, agricultural, and industrial classes of the Registrar-General nearly half a million of them are included.) And yet the losses of work due to sickness among children must be very large. Consider the time which might be spent in good productive work, if it were not spent in taking taking care of them while they are ill. Consider, too, the number of those who, through disease in childhood, are made more susceptible of disease in later life, or are crippled, or in some way permanently damaged; such as those who become deaf in scarlet fever, or deformed in scrofula or rickets, or feeble and constantly invalid, so that they are never fit for more than half-work, or for work which is only half well done. These losses can not be counted, but they must be large; and there are others more nearly within reckoning; the losses, namely, which are due to the deaths of those who die young. If they had lived to work, their earnings would have been more than sufficient to repay it; but they have died, and their cost is gone without return. The mortality of children under fifteen in 1882 was nearly a quarter of a million; what have they cost? If you say only £8 a piece, there are more than £2,000,000 sterling thus lost every year. But they have cost much more than this, and much more still is lost by the loss of the work they might have lived to do.
It is, indeed, held, I believe, by some that these things should not be counted as losses; that we have a surplus of population, and that really the deaths of children, though they may be the subjects of a sentimental sorrow, can not reasonably be regretted. I can not bring myself to admit that such a thing should even be argued. I have lived long in the work of a profession which holds that wherever there is human life it must be preserved; made happy, if that can be; but, in any case, if possible, preserved; and no argument of expediency shall ever make me believe that this is wrong. Indeed, I am rather ashamed—even for the purpose I have in view—to use so low an argument as that of expediency in favor of the saving of health and of life. I am ashamed of making money appear as a motive for doing things for which sufficient motives might be found in charity and sympathy, and the happiness of using useful knowledge; but it seems certain that these are not yet enough for all that should be done for the promotion of the national health; therefore, it seems well to add to them any motives that are not dishonorable; and so I add this, that we lose largely not only in happiness but in wealth by the deaths of these poor children.
I will add only one more illustration of these losses, which is always suggested by looking at tables of mortality. The deaths of persons between twenty-five and forty-five years old, that is during what may be deemed the twenty best working years of life, are annually between 60,000 and 70,000; in 1882 they were 66,000. Think, now, of the work lost by these deaths; and of how much of it might have been saved by better sanitary provisions. If one looks at the causes of their deaths, it is certain that many might have been prevented, or, at least, deferred. Say that they might have lived an average of two years more; and we should have had in this year and last an increase of work equivalent to that of at least 6,000,000 weeks; as much, in other words, as 6,000,000 people could do in one week.
More instances of losses of work by sickness and premature death might easily be given, but not easily listened to in this huge hall. Let these suffice to show something of our enormous annual loss, not only of personal and domestic happiness—that is past imagining—but of national power and wealth. Surely we ought to strive more against it.
But, some may ask, can these things be prevented? are they not inevitable consequences of the manner of life in which we choose or are compelled to live? No; certainly they are not. No one who lives among the sick can doubt that a very large proportion of the sickness and the loss of work which he sees might have been prevented; or can doubt that, in every succeeding generation, a larger proportion still may be averted, if only all men will strive that it may be so.
Let me enumerate some of the chief sources of the waste as they appear to one's self in practice.
Of the infectious fevers, small-pox might be rendered nearly harmless by complete and careful vaccination. Typhus and typhoid, scarlet fever and measles might, with proper guards against infection, be confined within very narrow limits. So, probably, might whooping-cough and diphtheria.
Of the special diseases of artisans there are very few of which the causes might not be almost wholly set aside. Of the accidents to which they are especially liable, the greater part, by far, are due to carelessness.
Of the diseases due to bad food and mere filth; to intemperance; to immorality—in so far as these are self-induced—they might, by self-control and virtue, be excluded. And with these, scrofula, rickets, scurvy, and all the wide-spread defects related to them, these might be greatly diminished.
It can only be a guess, but I am sure it is not a reckless one, if I say that of all the losses of work of which I have spoken, of all the millions of weeks sadly spent and sadly wasted, a fourth part might have been saved, and that, henceforth, if people will have it so, a still larger proportion may be saved.
We may become the more sure of what may be done by looking at what has been done already. Let me show some of it; it will be a relief to see something of the brighter side of this picture.
In a remarkable paper lately read before the Statistical Society, Dr. Longstaff says, "One of the most striking facts of the day, from the statistician's point of view, is the remarkably low death-rate that has prevailed in this country during the last eight years." In these years the annual death-rate has been less than in the previous eight years in the proportion of two deaths to every 1,000 persons living. The average number of deaths has been 50,000 less in the last than in the previous eight years. Doubtless many things have contributed to this grand result, and it is not possible to say how much is due to each of them; but it would be unreasonable to doubt that the chief good influence has been in all the improved means for the care of health which recent years have produced. This is made nearly certain by the fact that the largest gains of life have been in the diminution of the deaths from fever, and of the deaths in children under fifteen years old; for these are the very classes on which good sanitary measures would have most influence.
The annual number of deaths from typhus, typhoid, and the unnamed fevers, has been about 11,000 less than it was about twenty years ago. The annual number of deaths of children under five years old has been about 22,000 less than it was; and that of children between five and fifteen has been upward of 8,000 less.
These are large results, and, though they tell only of deaths, yet they bear on the chief subject I have brought before you—the working power of the nation; for, however much we might assign to improved methods of medical treatment of fever, yet the diminished number of deaths means a very large diminution in the total number of cases. The deaths during the working years of life were 6,500 less; and, this being so, we may hold that, if the average mortality was, say, twenty-five per cent, the diminution in the total number of cases must have been at least 25,000; and if we may believe, as before, that each of these involved ten weeks of sickness, we have, in these fevers alone, a clear saving of 185,000 weeks' work in every year.
And so with the diminution of the mortality among children, there must have been a greater diminution in the number of costly and work-wasting illnesses, and a large saving of money that would otherwise have been sunk. And not only so: but many of the children saved in the last eight years will become bread-winners or care-keepers; and who can tell what some of them will become; or what the world would have lost if it had lost all of them?
Let me add only one more reckoning. In a paper last year, at the Statistical Society, Mr. Noel Humphreys showed that "if the English death-rate should continue at the low average of the five years 1876-'80, the mean duration of male life in this country would be increased by two years, and that of female life by no less than 3·4 years as compared with the English life-table." And he showed further that "among males seventy per cent and among females sixtyfive per cent of this increased life would be lived between the ages of twenty and sixty years, or during the most useful period."
I should like to be able to tell the value in working-power of such an addition to our lives. It is equal to an addition of more than four per cent to the annual value of all the industry, mental and material, of the country.
But some will say—admitting that it is desirable, seeing how keen the struggle for maintenance already is. Can more than this be done? and the answer may be and must be. Much more. In this, as in every case of the kind, every fruit of knowledge brings us within reach of something better. While men are exercising the knowledge they possess, they may be always gaining more. This Exhibition has scores of things which are better helps to national health than those of the same kind which we had twenty years ago, and with which the gains already made were won. If I were not in near official relation with the jurors, I would name some of them: there are truly splendid works among them.
But do not let me seem to disparage the past in praising the present. It is difficult to speak with gratitude enough of what has been done, even though we may see, now, ways to the yet better.
Any one, who has studied the sources of disease during the last thirty years, can tell how and where it has diminished. There is less from intemperance, less from immorality; we have better, cheaper, and more various food; far more and cheaper clothing; far more and healthier recreations. We have, on the whole, better houses, and better drains; better water and air; and better ways of using them. The care and skill with which the sick are treated in hospitals, infirmaries, and even private houses, are far greater than they were; the improvement and extension of nursing are more than can be described; the care which the rich bestow on the poor, whom they visit in their own homes, is every day saving health and life; and, even more effectual than any of these, is the work done by the medical officers of health, and all the sanitary authorities now active and influential in every part of the kingdom.
Good as all this work has been, we may be sure it may become better. The forces which have impelled it may still be relied on. We need not fear that charity will become cool, or philanthropy inactive, or that the hatred of evil will become indifference. Science will not cease to search for knowledge, or to make it useful when she can; we shall not see less than we do now, and here, of the good results of enterprise and rivalry, and of the sense of duty and the sorrow of shame that there should be evil in the land.
What more, then, it may be asked, is wanted? I answer, that which I have tried to stir: a larger and more practical recognition of the value and happiness of good national health; a wider study and practice of all the methods of promoting it; or, at least, a more ready and liberal help to those who are striving to promote it. In one sentence, we want the complete fulfillment of the design of this Exhibition, with all the means toward health and knowledge that are shown in it, and with its hand-books, lectures, conferences, and the verdicts of its juries.
We want more ambition for health. I should like to see a personal ambition for renown in health as keen as is that for bravery, or for beauty, or for success in our athletic games and field-sports. I wish there were such an ambition for the most perfect national health as there is for national renown for war, or in art or commerce. And let me end soon by briefly saying what I think such health should be.
I spoke of the pattern healthy man as one who can do his work vigorously wherever and whatever it may be. It is this union of strength with a comparative indifference to the external conditions of life, and a ready self-adjustment to their changes, which is a distinctive characteristic of the best health. He should not be deemed thoroughly healthy who is made better or worse, more or less fit for work, by every change of weather or of food; nor he who, in order that he may do his work, is bound to exact rules of living. It is good to observe rules, and to some they are absolutely necessary, but it is better to need none but those of moderation, and, observing these, to be able and willing to live and work hard in the widest variations of food, air, clothing, and all the other sustenances of life.
And this, which is a sign of the best personal health, is essential to the best national health. For in a great nation, distributed among its people, there should be powers suited to the greatest possible variety of work. No form or depth of knowledge should be beyond the attainment of some among them; no art should be beyond its reach; it should be excellent in every form of work. And, that its various powers may have free exercise and influence in the world, it must have, besides, distributed among its people, abilities to live healthily wherever work must be or can be done.
Herein is the essential bond between health and education; herein is one of the motives for the combination of the two within the purpose of this Exhibition; I do not know whether health or knowledge contributes most to the prosperity of a nation; but no nation can prosper which does not equally promote both; they should be deemed twin forces, for either of them without the other has only half the power for good that it should have.
It is said, whether as fact or fable, that the pursuit of science and of all the higher learning followed on the first exercise of the humanity which spared the lives of sick and weakly children; for that these children being allowed to live, though unfit for war and self- maintenance, became thinkers and inventors. But learning is not now dependent on invalids; minds are not the better now for having to work in feeble bodies; each nation needs, for its full international influence, both health and knowledge, and such various and variable health, that there should be few places on earth or water in which some of its people can not live, and multiply, and be prosperous.
If, therefore, we or any other people are to continue ambitious for the extension of that higher mental power of which we boast, or for the success of the bold spirit of enterprise with which we seek to replenish the earth and subdue it; if we desire that the lessons of Christianity and of true civilization should be spread over the world, we must strive for an abundance of this national health—tough, pliant, and elastic—ready and fit for any good work anywhere.—Journal of the Society of Arts.