Statistics on the Nation's Health

Maurice H. Friedman, M. D.
Washington, D. C.
Presented at the 1947 Annual Meeting of the
Association of American Physicians and Surgeons
We should not expect that every one
will approach the problem of medical
care with the same philosophy. Nor
should we expect that every one would
arrive at the same conclusions after a
critical study of a body of unimpeach-
able data. Even among practising phy-
sicians there are bound to be differences
of opinion, and there is no why
we should not respect these d1fferences
if they are honestly arrived at. Never-
theless regardless of philosophy and re-
of differences of viewpoint,
honest men should be able to agree on
what are the facts in the case.
The raw data relevant to the problem
of medical care are not hidden deeply
in inaccessible caches. They are avail-
able to all who can afford the time to
look at them. But these original data
are not cited in public discussions on
medical care. Instead, the public is be-
ing fed half-truths and untruths tor-
tured from this body of raw data, frag-
mented, selected, and reassembled to
>nit the particular purpose of the per-
son using them. One looks in vain for
an impartial and scholarly discussion of
this problem either in our governmental
tmblications or in the. daily p;ess. In
order to further their own pohc1es sqme
of the proponents of compulsory health
insurance have painted a dismal picture
of medical care in this country. Accord-
ing to them the medical care a family
receives is largely, if not entirely, de-
pendent upon the family income. Fami-
14
lies o low have more illness
than familes of higher income and are
unable to secure medical care because of
the economic barrier. In the words of
J\Ir. Altmeyer, Chairman of the Social
Security Board "There are many Ameri-
cans this very minute who are suffering
and dying needlessly for lack of medical
care." The need therefore, is acute, and
there is no time for experimentation
with voluntary insurance plans. The
health of our Nation is in such precar-
ious state that we must immediately
surrender the control of medical care to
some Federal Bureau which will operate
a comprehensive, compulsory health in-
surance plan.
No rational person would claim that
the medical care in this country is al-
together satisfactory. For the conscien-
tious physician, interested in the welfare
of his community, the medical care
offered will never be satisfactory. Re-
gardless of what we have already
complishcd, and what we may
in the immediate future, we shall stlll
continue to strive for something better.
But in order to effect any real improve-
ment either in the quality or the distri-
bution of medical care we must know
what are the real deficiencies, and where
we can most effectively apply our ener-
gies. For <1 proper evaluation of these
deficiencies we need an honest and
critical analysis of the data now avail-
able.
Probably no point has been stressed
more by the proponents of compulsory
health insurance than the country-wide
rejections by the Selective Service
Board. vVilliam Green, of the American
Federation of Labor told the Senate
Committee on Labor and Public Welfare
that "Working people were shocked,
just as other people were by the extent
of physical unfitness that was revealed
by the Selective Service examinations."
Similar statements were made by James
B. Carey, of the C. I. 0., Leon Hender-
son, Harold Ickes, and repeatedly by
Senators Murray and Pepper. President
Truman in his message to the 79th Con-
gress used the Selective Service Sta-
tistics as one of his main arguments in
his plea for the enactment of legisla-
tion for a National Health Program.
However sincere these men are it is
readily apparent that they are not ex-
perts in' the field of medical care. It is
obvious that they depended upon some-
one else for factual material, and it is
equally obvious that the source of the
"factual" material is the Bureau of Re-
search and Statistics of the Social Se-
curity Board. In a pamphlet prepared
for the Senate Committee on Labor and
Public Welfare by this Bureau, under
the direction of I. S. Falk, the statement
is made that "Of 16,000,000 youths
examined fully half were unfit for mili-
tary service. The nature of the defects
among the rej ectees suggests that half
to two thirds of the defects could have
. been prevented or rehabilitated with
timely care."
As can be seen from the following
analysis of the Selective Service Data,
the defects uncovered by the draft ex-
aminations have little significance with
respect to the Nation's health. Any
statement to the effect that one-half to
two-thirds of such defects are prevent-
able or remediable is utterly false.
The assumption is generally made,
usually tacitly, that the statistical sam-
ple examined by the draft boards was
truly representative of the young, male,
15
adult population of this country. This
is not quite true. Between December 7,
1941 and December 31, 1943 the draft
boards selected about 10,000,000 men
for examination, and of these about 3.6
million were rejected. This represents
a rejection rate of 36%. During this
same period of time 2.7 million men en-
listed in the armed forces. If these
physically fit men arc added to the total
of 10,000,000 examined by the draft
boards the total number of men exam-
ined for military service during this
period then becomes 12.7 million, and the
rejection rate drops to 28.4%. After the
enlistment of the 2.7 million men, 37.5%
of th<" remaining men were deferred
because of essential occupation or de-
pendency. Therefore the population
subjected to medical examinations by the
Selecti 1c Service Boards was the adult
male population of the U. S., minus
those physically fit individuals who en-
listed, and minus about 38% of the bal-
ance who were deferred because of their
particular value to war industry or to
their families.
From the data furnished by the Se-
lective Service Bulletins it is not pos-
sible to evaluate every rejection listed.
This is largely because the information
under certain categories of rejections is
not suff1ciently detailed. For example,
under rejections for diseases of the
lungs the headings are 1) asthma, and
2) other lung defects. For such un-
specified CClnditions, as for "other dis-
cast's of the eye" "urinary, laboratory
findings only," "abdominal viscera, other
than ulcer" it is obviously impossible to
determine if such defects are amenable
to medical treatment. Rejections for
such ambiguous reasons represented
about 12% of the totaL
The remainder of the rejections can
be examined under separate categories,
such as I) conditions beyond the prov-
ince of the medical profession, 2) not
preventable and not remediable, 3) not
preventable, hut correctable, and 4) pre-
ventable, and/ or correctable. I have
examined all causes for rejection as
furnished by the Selective Service sta-
tistics and have done my best to place
each rejection in one of the above cate-
gories.
You, as physicians, will easily under-
stand why we may classify as not pre-
ventable and not remediable for military
service such conditions as congenital
heart disease, rheumatic heart disease,
hypertension, congenital absence of a
testicle, diabetes, etc. You will also
understand why peptic ulcer is placed
in this category, even though the symp-
toms may be held under control for
many years-if not permanently. The
situation is similar with asthma. One
can relieve the patient of his symptoms
lmt one cannot erase the disease and
make the individual acceptable to the
Army or the Navy.
Under the heading of "Correctable"
or "Preventable and/ or Correctable"
many more rejections have been included
than would be justified by a judicious
review of each case. In many cases the
abnormality, such as enlarged tonsils,
hemorrhoids, hernia, pilonidal cyst, etc.,
was not sufficient to interfere with the
ordinary demands of civilian life and
was not a cause of discomfort or disa-
bility. Certainly, in many cases, the
sober opinion of the physician would be
against surgical intenention. Yet in
order to be more than fair to our op-
ponents in this question I have included
as preventable or correctable all such
cases and also all cases of deafness or
defective hearing, all cases of otitis
media or perforate tympanic membrane,
and all defects of teeth. Regardless of
our success in treating these conditions
at the present time, the medical pro-
fession with the theraputic means then
at hand, most certainly could not have
prevented or corrected all these defects
when they first appeared in these men
some 5, 10, or 15 years previously. Con-
sequently the inclusion of all cases of
such defects definitely overstates the
number of rejections which could have
been prevented or corrected by medical
care.
You as physicians will also easily
understand my entries under conditions
which are beyond the province of the
medical profession. The items "Non-
:\Iedical" and "llliteracy and Mental
Deficiency" need no further comment.
The lay public, however, would not
quickly understand my reasons of in-
cluding venereal disease under this head-
ing, particularly in view of our posses-
sion of effective drugs for the treatment
u these diseases. This very situation
high lights one aspect of medical care
which is not full)+ appreciated by those
who have no practical experience. You
may recall that the armed forces had
more physicians per thousand popula-
tion than any civilian community could
hope to have (actually- about 4 doctors
per thousand troop strength). The serv-
ices of these doctors were freely avail-
able without cost to the individual. By
vigorous campaigns the medical depart-
ment and the VD control officers urged
the troops to take advantage of these
services. In contrast to the conditions
in World \Var I men who voluntarily
disclosed venereal infection suffered no
loss of pay and no punishment. Did this
generous provision of free medical serv-
ice prevent venereal disease in the armed
forces? Absolutely not-venereal dis-
ease was rampant in every establishment
in the armed forces. It is clear there-
fore that the prevalence of venereal dis-
ease is no reflection either on the ade-
quacy of medical care or on the cost of
medical care. Primarily, this is a social
and not a medical problem.
16
Rejections for conditions outside the
province of the medical profession
amounted to about 20% of the total.
Another 48% of the rejections were for
conditions which are beyond the powers
of the medical profession to prevent or
correct, so that about two-thirds of all
the rejections could not have been
a voided regardless of the distribution
or the cost of medical care. For 12%
of the rejections the information fur-
nished is insufficient to justify any eval-
uation. This leaves only 20% of all
rejections which could have been infiu-
medical care, and this figure
IS defimtely on the high side, because of
our liberality in classification and be-
cause the eradication of every defect
among the rejectecs would demand:
I) every person with such abnormality
woul_d. medical attention, 2) that the
phys1c1an 111 charge recommend
tive including major surgery,
m every mstancc, 3) that the patient
accepts the recommendation in every
mstance, and 4) that the recommended
procedures would be 100% effective in
every instance. \Ve all may wish for
such. ideal conditions in our private
prac!Jce, but as physicians we know onlv
too well that our daily experience doe-s
not justify any hope of such attainment.
In brief, of all the rejections by the
Selective Service System no more than
20% could have been influenced bv the
cost or the distribution of medical care.
Therefore the rejection rate for causes
amenable to medical care was about 6%
(i.e., 20% of 29%).
The proponents of compulsory tn
surance have mane much of the fact
that the Selective Service rejection rate
for Negroes was consistently higher
than for white men, and much higher
for men from the rural South than from
the Northern States. The inference is
d_rawn that. these differentials in rejec-
tion rates were due to the lower income
of the negroes and a lack of adequate
medical care, especiallv in the rural
regions of the South. Thus the members
of the Social Security Board who pre-
pared Senate Committee Print #4 (79th
Congress) concluded that these and
other similar differentials in rejection
rates "leave no doubt that these rates
were as high as they were becauseof
past medical neglect."
Because of such sentiments it is
especially important that we consider in
somewhat more detail the rejection
17
statistics for Negroes. Syphilis was re-
sponsible for 30.4% of rejections and
gonorrhea for 3.2%. Mental deficiency
chmmatcd another 21.4%, and mental
disease, 5.8%. Thus, venereal disease
mental deficiency and mental diseas;
for about 60% of Negro re-
JectiOns. If we examine, instead of the
percentage of total rejections, the actual
number of all defects found per thou-
sand m.en examined, thete are only three
categories in which the number of de-
fects among Negroes exceeded the num-
ber found in white men. These three
categories are: 1) venereal disease, 2)
cducatwnal ancl mental deficiency, and
3) cardwvascular disease. The greater
of cardiovascular defects among
the I\ cgrocs was due entirelv to the
higher incidence o among
the colored men. With the exception of
these three kinds of defects-kinds of
defects which could not have been in-
fluenced by more or better medical care
--the number of defects per thousand
N egrocs was significantly lower than in
the white man for every class of defect
listed !Jy the Selective Service System.
I should like to call your attention par-
ticularly to those defects for which the
neclical profession could be expected
do something. Under hernia we find
.S2.1 cases per thousand white men exam-
ined and only 40.2 for every thousand
Negroes. For hemorrhoids the compar-
ahk figures arc 11.6 (white) and 9.1
(Negro) ; and for varicose veins, 17.3
(white) nrsus 9.7 (Negro). Under
t:eo]Jiasms (really pilonidal cysts) the
hgures are 10.2 (white ) and 4. 9
(Negro). Teeth defects were noted in
124.7 whites and only 47.7 Negroes. The
data on tuberculosis is especially signifi-
cant. This disease was found in 19.9
per thousand white men and 14.6 per
thousand Negroes. If we were to use
the same kind of logic as is being used
by the proponents of compulsory health
insurance we would conclude that with
respect to tHberculosis the Negro is
gettmg better medical care than the
white. Ob,iously, such conclusion is in-
defensible-especially since the death
rate for tuberculosis is much higher in
the Negro than in the white man. The
point that should be made !S statis-
tics of the Selective SerVIce System are
not really relevant to the present d!s-
.:ussions. No man who was both compe-
tent and honest would attempt to use
these statistics in any argument for or
against any particular program of medi-
cal care.
The statistical support for the exist-
ance of an economic barrier to good
medical care is also subject to consider-
able question. The claim has been
that the volume of medical care received
by a family is largely, if not wholly,
dependent upon the fa:nily and
that the incidence of Illness IS h1ghest
in the low income groups.
If we look at the original data of
Falk, Klem and Sinai, as published by
the Committee on the Costs of l\fed1cal
Care, we see that the of illness
is lowest in the lowest mcome g_roups
and rises progressiYciy with
ment in family income to be highest 1_n
the highest income groups. Th1s. IS
exactly the opposite of what Dr. Falk
has been telling the Senate Committee
and what the newspapers have been pub-
lishing as a result of the material furn-
ished bv Dr. Falk and his colleagues.
I was surprised when I saw
these original data of Falk, Klcm ancl
Sinai, for I had expected the itH;idence
of illness to be higher in the low mcome
groups. However, when one
the age distribution of each mco_me
group there is less reason for surpnse.
We note that the number of older per-
sons was much higher in the high income
groups than in the low ipcome groups.
Indeed the number over 45 years of age
in the highest income groups was
least twice as great as the number 111
the lowest income groups. In view of the
much higher incidence of disease in the
older age groups, especially serious.
chronic disease, it is not so surpnsmg
that Falk found a higher disease rate
in the higher income groups.
I am aware of the Public Health Sur-
vey conducted in 1935 and 1936, and I
am cognizant of claims made, on the
basis of citations from this survey, that
there is a very definite relation between
income and incidence of disease. Wide-
spread publicity has been given to the
article on medical care in the report of
the 20th Century Fund. It should
noted here that the section on pubhc
licalth and medical care was written by
).I argarct Klem, an associate of J?r.
Falk. It should also be noted that M1ss
Klem has perpetuated in this article the
same errors and distortions of Se-
lccti 1 e Service Statistics. \Vhat IS more
striking is the deliberate selection of
;hose parts of the data of the Public
Health Survey which could be used
further the thesis of the economic
for disease, despite the fact that_ the pic-
ture given by the complete data 1s some-
thing quite different.
18
There is not sufficient time to subject
this data to a detailed analysis at this
moment. I should like for you to
sider, however, two important pomts.
First of all, the data were gathered .by
untrained persons taken from the
rnll s in those years. The lack of details
concerning the type of illness reported,
the inadequate definition of terms, a_nd
vagueness of classification are all stig-
mata of this kind of work. Only 35%
of the reported illnesses were verified
bv reports from physicians. Yet, assum-
that these data are entirely correct,
thev do not justify the picture presented.
T n her article for the 20th Century Fund
Miss Klem contrasts the incidence of
illness in the families of the very high-
est income brackets with that in the
families on relief. It is quite true that
there was more illness reported in relief
families than in those with the very
!1ighest incomes, (table 1) but if one
excludes the relief families the
tion of incidence of disease with family
income is not a good one. Once an an-
nual family incom1o0 of $1,000 is reached
there is no significant correlation be-
tween family income and the incidence
of disease. I feel certain that an im-
partial survey of our population would
disclose certain diseases in which the
economic status of the individual is a
definite factor, though perhaps indi-
rectly, working thru the effects of inade-
quate housing, nutrition, and sanitation.
The medical profession would welcome
reliable data on these points, but neither
the medical profession nor the lay pub-
lic stands to profit from the kind of
presentation now being offered by per-
sons who are more interested in mis-
sionary work for their cause than in the
dissemination of our existing knowledge.
You may recall that the Committee on
the Costs of Medical Care investigated
the volume of medical and dental sen--
ices available to people of each len! of
family income. To facilitate the com-
parisons, I have calculated the volume
of care in each category as the percent
of the volume received by the lowest
income group. You will note (table 2)
that there is a progressive rise of the
volume of dental services with each in-
crement of family income, so that the
people earning $2,000 to $3,000 per year
received more than twice as much dental
care as the people who earned less than
$1,200. On the other hand, with
to physicians' calls or visits, the people
with family incomes of $2,000 to $3,000
received only 20% more care than the
people in the lowest income bracket. At
this point, I should like again to call
your attention to the fact that the pro-
portion of older persons was progres-
sively higher as family income increased,
so that we should expect not only a
higher incidence of illness, as was actu-
ally found, but also a higher incidence
of the serious, degenerative diseases
characteristic of older people. With re-
spect to hospital care there is no cor-
relation whatsoever between family in-
come and volume of care. Similar!:.
there is no correlation between family
19
income and health examinations or im-
munizations.
If all aspects of medical care were
dominated by the economic factor, and
if all types of service were equally af-
fected by this dominant factor, we should
expect that the volume of each kind of
medical care would rise progressively
with income, and that the rising curve
for each kind of service would parallel
that for every other kind of medical
sen ice. But the curves relating volume
of services to family income are not
parallel. They vary independently of
each other. We must therefore conclude
that if there is an economic barrier to
medical care, it does not affect all types
uf medical service equally. \Ve must
also conclude that factors other than
the economic one are operative in the
distribution of medical care and that
they equal or exceed in importance the
economic factor.
The proponents of compulsory health
insurance do not broadcast the facts I
have just cited. Instead, they select
fragments of this very same body of
data (Committee on the Costs of Medi-
cal Care) and headline them to alarm
our people about widespread medical
neglect. For example, each of you has
many times seen in print the statement
in any one year 40% of our people go
without anv medical attention. This
citation is the original data of Dr.
Falk and his coworkers and is absolutely
correct. But what is not cited from the
data of these same authors is the fact
that 47% of our people go thru the year
without any illness. Therefore the num-
ber of persons who go without medical
care each vear is less than the number
who report no illness for the year. Prob-
ablv the statement which more than any
oth-er carries the innuendo of widespread
medical neglect is the one which says,
"37% of all illnesses, disabling and non-
disabling, reported by families earning
less than $1,200 per year were unat-
tended." Again the statement is taken
from the work of Falk and his collabo-
rators and again the citation is absolutely
correct. But what are these unattended
illnesses? According to Dr. Falk and
his colleagues one definition of an ill-
ness is "any condition for which 50 cents
or more were spent on drugs." Of all
illnesses recorded in their survey 47%
were not disabling; that is, did not in-
terfere with the usual activities of work,
school, or play. Eight percent were dis-
abling in that sense hut did not reqmre
the afflicted person to go to bed. In other
words, about half of all of recorded ill-
nesses allowed the patient to be up and
around and did not interfere with his
usual activities. Forty percent of these
"illnesses" were minor respiratory epi-
sodes or minor gastrointestinal upsets.
J s there any wonder that 37% of such
afflictions were unattended?
Although we have been blessed with
riches beyond those of other nations our
national resources are not unlimited. \Ve
cannot afford to dissipate our energies
on everv minor problem. There are
major which us. The.se
problems are concerned w1th thos_e dis-
eases which kill, such as heart d1sease,
cancer, nephritis, vascular disease, and
tuberculosis, and those diseases which
maim : mental disease, tuberculosis, vas-
cular disease, etc. You may note that
the same diseases appear in both groups.
To the extent that infection plays a role
in som<' of these diseases (pneumonia,
tuberculosis, and some forms of heart
disease), housing, density of population,
state of nutrition, and personal and puh-
lic hygiene are of great
Twenty to 40 percent of all heart
ease, depending upon the geography, :s
due to rheumatic fever. It has been esti-
mated that 1 percent of all school chil-
dren have rheumatic heart disease. Med-
ical care alone will not be of much value
in this problem. Medical care will enable
the stricken individuals to lead more
nearly normal lives and perhaps extend
their life span, but no amount of medi-
cal care can prevent rheumatic heart
disease. At this moment in medical his-
tory we do not have the means of pre-
\ention. .,
Mental disease is listed by the Nat-
tiona! Health Survey as the leading cause
for prolonged disability. It is appropri-
ate in this connection to cite the work
of Hyde and his co-workers on the socio-
economic factors of this type of disease.
\Vith respect to mental deficiency the
grade of the community (economic level,
educational and recreational facilities,
etc.) was the most important factor.
The cultural and ethnic background was
almost as important (mental deficiency
was almost nonexistant in the Irish and
the Jews regardless of the type of com-
munity). Population density was of no
importance. The community grade
seemed to haH no effect on the incidence
of chronic alcoholism, but density of
population was the most important fac-
tor, along with cultural, ethnic, and _re-
ligious background (chronic alcohohsm
heing rare among Jews and almost non-
existent in the Chinese). With respect
to psychoneurosis, which includes a very
large proportion of the cases of.
disea,c, population density had httle 111-
flnencc. But the ethnic background and
community grade were of great import-
ance. This is no place for the detailed
examination of the causes of mental
rlismse, but I do wish to point out that
the frequency of one type or another. of
m<:"ntal disease is not simply a reflectiOn
of the presence or absence of medical
care.
20
I think we should re-examine the place
of the physician in the community. I
think we could expand to infinity our
medical facilities without influencing
significantly the incidence of many of
our kading causes of death or disability.
The physicians are not responsible for
our present housing conditions. Nor are
they responsible for the inadequate edu-
cational facilities in many of our states.
Neither by the administration of pills
from a little bottle, by universal inocu-
lations, by X-ray therapy, by the use of
radioactive elements nor any fancy
gadgets physicians quickly, cheaply,
effectively erase the consequences of
overcrowding, undernutrition,
madequate plumbing, and the widespread
of personal and public hygiene.
1 he med1cal profession alone cannot
shield the entire population from the
effects of economic maladjustments.
Table I
Statistics from the National Survey, U. S. Public Health Service, 1935-1936
Famlly Income Group
Relief
Less than
$1,000
119
$1,000 to
$2,000
117
$2,000 to Greater than
Acute Diseases .................. 163
$3,000 $3,000
Chronic Diseases .............. 71
113 111
54 38
37 38
Table 2
The
Volume of l\!le<.Iical Services Received by ln<.lividuals in Families of Stated
Incomes--Expressed as Percent of Volume of Lowest Income Group
Family Income
Under $1,200 to $2,000 to$3,000 to $5,000 to
Service $1,200 $2,000 $3,000 $5,000 $10,000
Doctor's Calls ...................... 100 105 119 156 188
Dental Care .......................... 100 155 210 260 378
Hospital Days ...................... 100 72 82 65 90
Health Examinations ........ 100 82 82 100 280
Immunizations ...................... 100 71 74 87 121
21
Over
$10,000
245
525
129
1,100
175