mately 55 per cent. At any rate, the loss ratio to date shows conclusively that the fund has not been swamped by an influx of uninsurable risks, as its opponents predicted.

Another alleged disadvantage of state fund insurance, upon which great stress is laid by its opponents, is the possibility of political control or manipulation, with resulting high cost and poor service. It is argued that no state fund can be administered economically and efficiently, and that the waste and graft which will inevitably creep into the administration will more than offset any theoretical economies claimed for state enterprise in this field. The history of the New York state insurance fund to date affords no support for this argument. Politics has played no part in the selection of employees and in the management of the fund. The employees, including the heads of departments, are all under civil service. The management has demonstrated the possibility of giving a clean, businesslike, non-political administration of a state fund. It seems inconceivable that politics will be allowed to creep into the administration of the fund in the future. This fund is in reality a trust fund, made up of money contributed by employers for the benefit of injured employees and their dependents. The interest of both employers and employees is that the fund be administered solely with regard to economy and efficiency, in order that the benefits prescribed by the act may be provided for employees at the lowest cost to employers. The cooperation of employers and employees may be depended upon to support an administration of the fund in strict accordance with sound business and insurance principles. It is safe to predict that this policy is the only one that will ever be tolerated by the manufacturers and working people of the state, whose interests at stake in the fund are too large to permit them to view with indifference any attempt at political interference.

THE SOCIAL COST OF SICKNESS

HAVEN EMERSON

Commissioner, Department of Health, City of New York

Two lines of approach are open to those who would analyze the cost of sickness. The accountant and the statistician will attempt to estimate the number of people sick enough to affect their daily work, and this must be a guess pure and simple, and then calculate certain expenses of medicinal and nursing care, the wages lost, the impaired capacity to work. They may even refer to damage suits and court decisions and count up the compensation value of pain and disability, the cost of foot or eye or paralyzed arm. The sanitarian and the sociologist, on the other hand, might count the services and equipment which would suffice to prevent the sickness we now experience.

Both the cost of the sickness as it is found to-day and the expense of prevention of such sickness as is preventable are acknowledged to be the burdens of society, even though for the moment the loss, the privation, the often permanent disintegration of the family, are confined to the three rooms of the city tenement or to the four walls of the mountain cabin.

The final distribution of the cost of the sudden catastrophe of a case of pneumonia is by spreading the burden, clumsily enough and unevenly, far and wide in the community.

So the cost of prevention may for the moment bear upon the farmer who must drain his stagnant marsh to spare his family and neighbors the devastation which the malarial mosquito would bring. It is not society at first which bears the cost of the deeper driven well and the sanitary privy which the rural dweller must provide if he would prevent the typhoid fever which decimates his village. The cost of such improvements postpones the payment on the farm mortgages, and is spoken of as confiscation when labor and tools for the necessaries of bare existence are hard enough to come by.

Which is the expense that society bears most willingly, the cost

of sickness and death or the cost of drainage and sanitation? Notice the liberality with which appeals are met when disease has selected its victim. The open purse, the helping hand, and the friendly heart are at the service of sickness when the appeal is personal, concrete, objective.

You pity the typhoid patient in the hospital ward, you supply him with the care necessary to insure his recovery. A competent hospital superintendent can tell you what the cost has been as far as the period of illness is concerned, and you think it reasonable. Would you feel responsible if called upon to pay the infinitely smaller bill incurred in tracing the cause of this individual case to its source? The patient's brother may lunch at the same counter and drink at the same polluted well's supply, but you do nothing to prevent such a calamity as a second case of the disease unless perhaps you write a letter criticising your local health officer, or even go so far as to resist by argument or even by force the offer of the district physician to vaccinate those exposed in the home of the patient when he was already infectious.

It is quite as correct to claim that the social cost of sickness is the cost of measures which will prevent sickness as it would be to put down in rows of interminable figures the loss in cash and happiness due to actual disease which has occurred. Furthermore, I believe the more accurate estimate will in every instance be the one based upon work done now for prevention which gives results, instead of counting the cost of sickness the end products of which may not be reached until the last mentally defective, generations hence, is allowed to pass its life without propagating its kind, or the grandchild of the syphilitic is buried and the family has come to an end.

Let us therefore measure what we have spent in the past as a goad for our efforts, to see that our costs in the future shall be to some profit.

Why waste time and breath discussing how much a life, a maimed arm, a blinded eye, a starved body has cost the community?

Society revels in the experience of to-day and in the promise of to-morrow, but has scant time to discuss its failures of yesterday.

Let us then seize the opportunity that science has put into our hands. Let us reap the harvest of health that awaits our application of simple measures, easily taught, quickly applied, and cheap as are all profitable expenses.

Sickness and disability are preventable in so large a measure that we need not quibble if the physicians of to-day have not decreased cancer or insanity, and if their patients still show too early in life the results of neglected hygienic laws.

Preventable sickness is either communicable and therefore to be attacked by cutting off the means of communication and the sources of distribution, or it is occupational and to be met by correcting the conditions under which we permit occupations.

It is only of a very few of the communicable diseases that we have anything approaching an accurate measure of their prevalence. We know that for every death from typhoid fever there are about ten cases which recover and still there are many parts of the country where the reporting of disease is so incomplete that more deaths will be recorded with the local registrar than there have been cases reported to the health officer. Without going into the cost of service of health officers, nurses, and sanitary inspectors, and the like, it would be correct to state that the social cost of investigating and stopping a typhoid epidemic is rarely as much as the cost of any one of the lives which typhoid takes, and that for every life lost nine more lives were more or less seriously damaged for considerable periods.

We know the cost of the service of prevention whether by purifying the water, pasteurizing the milk, or by keeping the typhoid carrier from our kitchens. The cost of an epidemic can only be approximated and goes beyond the community in which it starts, the visitor within its gates leaving for distant towns with his yet undeclared infection to start new foci of disease.

The idea of efficiency has been made to serve men of one aim, the aim to develop an occupation to the point of maximum production at the minimum of cost. Well and good, let us by all means have good shoes made cheaply. Let us have such manner of production that our people may get the benefit of the economies made possible by large undertakings, and where does the harm come? It is in the monotony of continuous and uniform tasks. It is in the noise, dust, and indoor conditions that prevail.

No one has ever mentioned the item of lowered individual resistance as one of the costs of production, and yet it would be as suitable to add to the cost of a shoe the expense of sickness made probable by the faulty sanitation of the factory and the hygiene

of the home, as it is to include in the costs of operation the indemnity paid for accidents for which the employer is responsible.

Shall we add to the social cost of sickness the cost of the alcohol used which is responsible for many of the industrial accidents, or shall we charge up only the campaign of education which will in the end prevail in teaching the avoidable defects in resistance and action which alcohol causes?

Society pays the cost of the liquor used and the still greater but less calculable cost of the damage it does. Society is beginning to take note of its liquor bill and it is wisely including it among the other unprofitable expenses. Alcohol, the habit-forming drug par excellence, is to be included with morphine and cocaine as among the antisocial and destructive forces. Is it conceivable that the teaching necessary to save our people from the sickness due to alcohol will cost as much as the annual bill now paid for alcoholic beverages, for lack of the knowledge of its damage to national health?

Ask any community to subscribe their annual expenditure on worthless patent medicines for the support of visiting nurses sufficient to reach each prospective mother just to give her the little word of brief instructions needed to save her from the fate of thousands of women who are annually sacrificed, ignorant of the needs of her time, helpless while her babe is dying.

The cost would be easy to bear, the results would appear within a year, and yet the social cost of sick babies and permanently invalided mothers has never been charged up to the community.

No returns are so prompt and so nearly exactly calculable as those from investment in personal teaching of the expectant mother and of the nursing mother.

Next comes the periodic examination of the growing child, the daily study by the school nurse and the doctor which has made our public schools centers for prevention of the contagious diseases instead of points of distribution of them. The cost to the community is small, but it is undertaken only reluctantly and grudgingly.

It may be desirable, even essential, for society to know every case of sickness, its cause and duration. A rough guess at the cost could be made, allowing for obvious expenses until recovery or death, but I would suggest that no estimate of cost in terms of money can even approximate the loss of happiness from sickness.