at the beginning of the year. The result has been a great reduction in sickness, a reduction in absenteeism from classes, and greatly increased student efficiency. The loss of time due to bed illness has been reduced 40 to 60 per cent, due to the early treatment of preventable conditions. The frequent consultations have reduced serious illness and its complications at least 50 per cent. During the eight years of this medical supervision the University death rate has been reduced to only one fourth of the general expectant rate, exclusive of tuberculosis, at the same age period, and even the death rate from the recent "flu" epidemic was believed to be only one fourth of the general death rate attributable to that cause.

Why should not something like this arrangement be extended to the entire population of the state and the nation? It does for 5000 of the great middle class by taxation what the very rich and the very poor have been getting in the great cities substantially free of cost to themselves.

The principal reason against extending it to the nation seems to be the opposition of doctors. The idea that people generally should consult them without paying for each consultation seems unusual to them. Consequently we have that ethics of the profession which permits heavy fees charged to wealthy patients in order to make up for the free service given to indigent patients. Even if there are no wealthy patients in the neighborhood, the doctor expects to render a considerable amount of service free of charge, or, what is the same thing, to carry a large account of uncollectable bills, and these charges must be met by correspondingly higher fees charged to the people who do pay their bills. It amounts to a tax on the wealthy and on the great middle class in order to give free service to a pauperized class or a class that is not ashamed to dodge its doctor's bills.

As a result, this great middle class of farmers, wage-earners, and people with moderate incomes, who will not accept free service, do not consult the doctors and pay the fees until they are compelled by sickness. They hold off, and doctor themselves, and buy patent medicines, until it is too late. If consultations were free, they doubtless would consult the doctors, as our students do, many times as often as they now do.

This is what I call prevention of sickness, and this is what health insurance means. It means free consultations, and it means payment

of the doctors, to that extent, out of a fund contributed in advance by the people and by the industries of the country. It means free consultations and free examinations and diagnoses supported by taxation through the medium of insurance funds. It means, instead of the physician's being compelled to constitute himself a tax assessor and tax collector on the wealthy and the middle class in order to furnish the poor with free service after they are sick, that the legislature shall create its own system of taxation in order that the doctor may freely serve all persons long before they get sick.

One of the principal obstacles, as I have just said, to the method of starting a health program by means of universal health insurance is the attitude of many doctors. Doctors have several reasons for suspicion. They know something about the contract doctors. They see mutual benefit societies let out contracts to the lowest bidder to take care of their members in sickness. But these mutual-benefit societies have the old idea of insurance as a philanthropic measure of relief, not the new idea of insurance as a means of preventing sickness. They look on sickness as inevitable and the doctor as a palliative. They get this idea largely from the doctors themselves. They have not yet fully learned from their doctors of the enormous advance that the past thirty years has made possible in preventive medicine. Neither have these mutual societies the business ability nor business inducement to prevent sickness that the employer has. Their purpose is charity, not business. These mutual societies will always have a most important part in a universal health program. They do one thing that neither the doctor nor the employer can do. The very fact that they let out contracts to the lowest bidders indicates that they try to keep down expenses. They assess themselves, and if expenses go up their assessments go up. For this reason they are careful to watch their members and to prevent them from feigning sickness and getting the benefits fraudulently. In this respect they can do what neither employers nor doctors can do without their help, and this is a reason why health-insurance programs propose greatly to enlarge the field of these mutual societies, and to require their members, as well as the employers, to contribute to the insurance funds. But their field is largely the care of unprevented sickness. Not until the business ability of the community is directed towards prevention can we expect that the enormous advances in medical

science of the past thirty years will be generally utilized. Then the doctor who bids on contracts will disappear, much as the oldtime factory inspector is giving way to the safety expert.

The other important obstacle to health insurance is the idea, not only of insurance experts but also of the public and of physicians and surgeons, that the work of the practicing physician is the art of healing the sick rather than the art of preventing their sickness. Those who are interested in the problem of tuberculosis are the pioneers in revising this mistaken view, for they realize, as others do not, how little can be accomplished without the complete organization of the profession and of the community for the purpose of discovery and prevention. It is fortunate that they have had their own association and their own funds, independent of the profession in general, for it is this that enables them to go ahead in their educational campaign of organization, legislation, and prevention, without waiting for others.

The work of the Tuberculosis Association reveals that palliatives and halfway measures are inadequate. It reveals to us, most of all, the need of a medical profession that shall be in truth the guardian of the public health as well as practitioners of the healing arta profession so organized that the wonderful developments of medical science shall reach every person, for the public health is nothing but the protection of each individual's health.

It reveals to us the need of placing this profession on a business basis instead of leaving its practitioners to the doubtful expedient of financing their calls for charity by taxing it up to the more wellto-do.

The work of the Tuberculosis Association reveals the need of enlisting the business ability of the nation in the campaign of prevention. Industry already pays an unseen tax in the absenteeism and inefficiency caused by sickness and poor physique. But not until this tax is made visible in terms of money, where it can be actually seen entering into the cost of manufacture, will business men generally look to the medical profession for assistance in reducing it. When the vigilance of business men is enlisted in the cause, then will the high aims of the new medical profession, which seeks to keep the nation healthy as well as cure its sickness, be more nearly realized. Medicine will more nearly become public medicine, but

liberated from politics. Health departments, in every town and rural district, instead of trying to do the work of prevention themselves unaided, will be the public agencies which furnish to the private practitioners the dispensaries, clinics, hospitals, sanatoria, school and county nurses, which make it financially possible for the private practitioners to add the work of prevention to their work of healing. A truly comprehensive health program is not restricted to any one thing. It means, of course, the cure of sickness. But it means, also, the personal coöperation of every private citizen in sickness prevention. It means the business enterprise of every capitalist and employer of labor. It means sickness insurance. It means increased taxation on unprevented sickness, with ultimately reduced taxation on property. It means, most of all, a medical profession able and willing to bring to the service of the entire nation the marvelous discoveries of the science of preventive medicine.

JOHN R. COMMONS

UNIVERSITY OF WISCONSIN

PART II. THE LABOR MARKET

VII

AUTOBIOGRAPHIES OF FLOATING LABORERS1

NUMBER

UMBER 2. Age fifty-six years, born in America, of American parents. Single. Still strong. When he was between twenty and twenty-five years of age he wanted to marry, but never had enough money to establish a home. He became a "regular" lumberjack. A "regular" lumberjack cannot marry, for he cannot take his wife to the camp, and it is of no use for her to live in the city. Secondly, if a man becomes a "regular" lumberjack, he is not fit for married life; he drinks, fights, and leads an immoral life. He does not know any trade. While a boy he wanted to learn mechanics, to become a worker in a machine shop, but he had no chance for this, for his folks were poor and he did not have a sense of how to go about learning this desired trade; his father was not very bright either he could not read and write. He himself had been in a public school for his education.

His father was a farmer, and he started to work on his father's farm when ten years of age, to do chores and every kind of farming work. His mother died when he was very young. As the farm was heavily mortgaged, it was sold; not much money was left.

When he was sixteen years of age he went into the lumber woods to provide for himself. He worked from fourteen to fifteen hours a day. The pay was, at the beginning, $18 a month and board. Laundry was done by the men themselves. Two men slept in a bunk; the bunks were in two stories. The bedding was hemlock brush, covered with a blanket. In the bunk house there was no iron stove, but just a fireplace called "kabuke." The foreman was a bad man, always hollering, abusing, ever dissatisfied with his men, and turning them out two hours before "they could see wolves." 1 From interviews made for the U. S. Industrial Relations Commission, 1914.