All we have done has only brought us face to face with the stern truth, that the control of tuberculosis must no longer be considered a medical problem, but a social problem. And as a social problem it can never be cured until we treat it socially.

And society will treat tuberculosis in a social way only when it treats all sickness in a social way, by means of social insurance. And when society treats all sickness by insurance, it will find that the suggestion made by Chester Rowell is true that it is cheaper, it costs less cash, to supply all those conditions necessary for keeping people well enough to earn their living, than it is to support them and their families when they are sick. Then and only then will the problem of tuberculosis find its real solution. Is this an insane idea? Well we must squarely face it, for social insurance is the problem of to-day, and is by all odds the largest problem before the medical profession.

We are in a transitional period, the individualistic system with its individual doctor, its individual patient, is passing; and in its place we will soon find the collectivistic method as is shown by the present tendency to social insurance which has for its object the prevention and cure of sickness on a collectivistic plan, just as society now prevents and cures ignorance by means of our public schools, the expense of which is a collectivistic and not an individualistic obligation.

In a democratic form of government the ignorance of one is the menace all, hence the education of each at the expense of all. This principle applies with as much force in the control of all infectious diseases as it does in the control of ignorance. The infection of one is the menace of all, hence the care and protection of each should be at the expense of all; and protection of society against tuberculosis means that each must have enough food, clothing, shelter, rest and recreation to keep his vital resistance above the invading level of tuberculosis. This means employment, wages, reasonable working hours, and proper care when ill from accidental causes. It means that society, as individuals, demands that society, as a whole, distribute the causes

of poverty and suffering by intelligent prevention, rather than by our present method of treating the end results, suffering, sickness, poverty and a large amount of crime, at an enormous and wasteful expense, or by a heartless and wicked neglect. Hence we have the foundation of social insurance laws against sickness and unemployment. It is just as sound in principle and just as profitable to keep people well, at public expense, as to keep them educated at public expense; it is quite as much in the interest of public welfare to cure sickness as to cure ignorDoesn't this idea of curing sickness at public expense sound like socialism and if so, is it not dangerous?

ance.

Socialism is a term we all dislike, but in using it as a label to hinder every movement in the interest of the people we have rather worked it overtime.

A railroad commission which compelled the railroad to work for the interest of the public as well as for private gains was socialistic.

The assumption by the state or municipality of the right to control the building of tenement houses for the poorer classes so that every man, woman and child, shall be given by every owner of rented property sufficient light and air for good health, is socialistic.

The compulsory education of every child for its own good and the good of the state at the expense of the public, is socialistic.

The control of public utilities such as gas, water and telephone companies, depriving them of the power to charge one patron more than another, or to make in any cases more than a reasonable charge, is socialistic.

Who could have foreseen that the same progressive forces which called the American Academy of Medicine into being would compel us to consider in such rapid sequence the topics just mentioned and many others, and bring us face to face with such popular movements as industrial insurance, health insurance, mothers' insurance and other national movements which add to the peace and prosperity of our commonwealth.

These efforts at social readjustment, based on the principle

that every industry should share the losses as well as the gains of its development and maintenance are so sound in their philosophy and so practical in their results that since 1883, when they were recognized by Germany, they have found expression on the statute books of almost every civilized nation.

Social insurance is so important to the medical profession that the American Medical Association recently appointed a special committee to study this problem.

The State Medical Society of California at its meeting in April last appointed a state committee on social insurance and requested every county society to appoint a similar committee to work in co-operation with a state insurance commission appointed last year by the governor, to the end that with the aid of physicians proper legislation might be constructed. I use that word constructed advisedly for much of the legislation with which we are afflicted was never constructed, it just happened and the fact that it just happened is not the only resemblance it bears to some of our other misfortunes. Even our legislators as well as our physicians seem slow to learn that society is readjusting itself.

Any attempt to establish such social insurance as will secure to the wage earner and his family protection from the disastrous effects of sickness presents as its most difficult problem any form of adjustment satisfactory to the medical profession.1

The British Health Insurance Act differs decidedly from that of other European countries in frankly recognizing this difficulty by way of a compromise between the interest of the physician and the interest of the insured."

And why not recognize both interests? In all countries insurance laws are formed to protect not only the insured but also safeguard the interest of the insurer.

Is not the world indebted alone to the medical profession for its wonderful progress in preventive medicine? And is there any good reason either in logic or morals why the progress of preventive medicine should be retarded by allowing the interests of the medical profession to be ignored or over-ridden? The

1 Rubinow.

Rubinow, Pamphlet, p. 345.

Academy would do well to urge on the part of the profession of the United States such co-operative consideration of these conflicting interests as will safeguard the future progress of preventive medicine.

Social insurance has not yet accomplished its mission. It is firmly established in almost every European country; in our American commonwealth it has just begun but it has already made of the questions of industrial insurance, health insurance, insurance against unemployment, the relation of the state to mother and children, definite problems that demand solution.

While the great movements for social readjustment have swept society like a mighty cyclone, the medical profession has had something of the attitude of the man who was visiting his friend on the broad prairies of Kansas and seeing for the first time a tornado he inquired of his friend, "Say, Jim, you have had some experience, can you tell me how I can stop that tornado?" "Yes, we have had some experience and we don't stop 'em; we find we are more successful to just go with them." The medical profession not only of the United States but throughout the world, by its open opposition to, or its aloofness from this movement for social insurance, is failing to render to humanity that service which is due in this period of social reconstruction.

One of the newest and most interesting phases of social insurance is that which touches on the relationship of the state to motherhood and children.

In 1891 a society was developed in France known as the Mutualite Maternelle. Although formed on the co-operative plan, its treasury received but a small amount from its members, most of the funds being supplied by the state and by private philanthropies. Its members were entitled to forty-eight francs at confinement and ten francs for nursing. This society was so successful that it stimulated the formation of many similar societies throughout Europe. To-day we find maternity insurnace in at least FOURTEEN COUNTRIES of Europe. These are all or nearly all co-operative, the employer, the employee and the state each contributing a definite proportion to a common fund.

Australia and France have a system of maternity insurance under which the state pays all the benefits.

The British laws provide for a benefit at confinement for the wives of all insured men and to all insured women, whether married or unmarried, and an additional sick benefit is paid to all insured women, provided, however, they are married. The British laws contain another very remarkable clause which states that "Medical benefit shall not include any right to medical treatment or attendance in respect to a confinement." The British medical profession surely was not in evidence when that law was enacted.

The first city in the United States to extend definite aid to mothers was San Francisco, in 1908; while Missouri must be given the credit for enacting the first mothers state pension law in 1911. Since then mothers pensions laws have been enacted in twenty-three states.1 California, Oregon, Washington, Idaho, Utah, Nevada, Arizona, Colorado, South Dakota, Minnesota, Nebraska, New Hampshire, Iowa, Missouri, Wisconsin, Illinois, Michigan, Ohio, Pennsylvania, New Jersey, Massachusetts, New York and Tennessee.

In all these countries, with the exception of Germany, and in all American states as far as I can learn with the exception of Colorado, the only recognized relationship existing between the state and motherhood and children is poverty.

Some one has said that "The first test of eligibility of mothers to state recognition is poverty." Is it? Or is it motherhood? The state recognizes poverty as poverty and relieves it in every condition of life. Whether or not the state should recognize and foster motherhood on the quality of which the existence of all free government depends is a question which will be discussed in the near future.

Italy recognized motherhood and not poverty as the first test and enacted a compulsory maternity insurance law in 1910, although she has no health insurance laws. This maternity law covers only working women who are employed; it is co-operation in that the employer, the employee and the state each contributes

1 Mothers' Pension, p. 2.