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Andrija Stampar, MD

Andrija Stampar, MD Photograph courtesy of the World Health Organization

GOLDSCHEID POINTS OUT that we are living in a world blind to true value. We can see only sudden catastrophes and have lost the power of sensing hidden, continuous misery everywhere in present-day economic and social life. We have understanding only of inorganic capital and know nothing about human capital. In a wholly capitalist economy, where the loss of human life is considered only as a private loss for the family but as no economic loss for society, the economy of people becomes, of course, completely superfluous.... Today we abhor the contests that used to be held in Roman arenas but do not realize that today only the scene has changed, because masses of working people are getting ruined in factories which are often a worse place than ancient arenas....

The entire life in present-day society is arranged in such a way that thousands and thousands of human beings are decaying for the sake of illusory success and even more illusory wealth. On the one hand, we have a great wealth of dead industrial products and are boasting of advances in our production, pointing out benefits deriving from it for public economy, and overlooking the fact that only the few profit by this economy; on the other hand, we do not see the legions of sick among craftsmen, factory workers, nor the mortality of children, nor tuberculosis, nor alcoholism among most working people: this means, on the one hand, wealth in dead things, and on the other, disease and death among the living. The whole national economy is enriched at the expense of people’s health....

All our efforts made so far toward the promotion of public health have been considered as charity, as acts of humanity, and that is why the budget allotted for these efforts has been so small, for the understanding of charity can be found only among the few. Social politics and social hygiene have not shown any remarkable results either, because they have been conducted along the same lines; a turning point will occur only when health policy is looked upon as the most important part of national economy....

All our efforts will fail until everybody enjoys the benefits of hygienic culture. It is in the economic leveling of society that the success of social hygiene lies. As early as 1848 Virchow said: "A sensible constitution is bound to guarantee real hygienic life to everybody." Examining the relation between disease and social conditions we are faced with a truth which indicts present-day hygienic culture very gravely: poverty is one of the most pronounced causes of disease.... This is a dark side of present-day culture, this state of affairs should be abolished by the rebirth of the maxim according to which human life is the only true currency, the only true wealth. Away with the perilous anomaly that thousands of people go to rack and ruin by producing luxurious articles, under conditions most detrimental to their health, to provide ephemeral joy to the spoilt rich classes....

The inadequacy of present-day health politics and social hygiene is perhaps not due to our not knowing all the fundamentals which govern them but to the fact that our sense of morality is not social but individual. Nowadays everything is considered from the standpoint of individual morality which in most cases is no morality at all but something quite opposed to it. These ethics are the result of bad management which aims at intensifying the economy of things without taking any account whatsoever of the economy of people.... There are a great many who only laugh at any emphasis on the ideals of justice and human rights. Social understanding is replaced by a merely individual one, which greatly obstructs the activity of national health politics.... At present we are going through a serious ethical crisis which will be overcome, and mankind will find the way toward ethical revival.... The health budget will not only comprise items relating to the help of the sick but will—to an undreamt-of extent—be used on preventive lines for the benefit of human material on which the nation’s attention will be focused. The war gave an impulse to all that, and developments in this direction cannot be stopped by any reaction....

In this country there are about 27 deaths per 1000 inhabitants a year. If we compare our mortality rates with those in other countries, we can see that on the average twice as many people among us die as in the majority of other European countries. For the whole country this means a permanent annual loss of 175,000 human lives.... Mortality due to tuberculosis (45%) is ahead of all other countries; venereal diseases have long been endemic in many parts of this country and their spreading was considerably intensified by the war: alcoholism (14 liters of absolute alcohol per person) puts us in the third place in Europe.... This kind of health deficit can easily be seen from statistics, but the deficit in non-hygienic conditions in villages and towns, in workshops, factories and hospitals, in a complete hygienic illiteracy not only among the widest but also among absolutely all national strata—of this deficit we are not aware, because our eyes are blind, and our ears deaf to it....

Health education has so far been carried out only by private initiative. The present time, however, calls for a more comprehensive participation of the state in this field of action.... Let the universities be the nurseries of health education, especially those preparing students for the professions that will bring them in contact with the people. Let future teachers acquaint themselves closely with the principles of school hygiene, future executive staffs with the principles of health policy, theologians with the hygiene of the parish, technicians within engineering and industrial hygiene, and farm workers with the principles of rural and food hygiene. Only by these methods can we educate people in a correct understanding of health needs and—what is even more valuable—in the ethical side of their duty to maintain health and prevent disease.

It would be a mistake if health education were restricted to the four walls of the classroom. Health education should continue and be carried out most intensively outside schools.... Popular lectures, organization of special courses, exhibitions, publication of relevant literature, posters, the setting up of schools and associations with particular tasks, all these are powerful tools....

Virchow, in his "Medical Reform," says: "Physicians are natural advocates of the poor, and social questions for the most part belong to their jurisdiction." Virchow’s opinion is still valid but has not been put in practice. Medical activities have begun to be drowned in purely materialistic waters, greatly resembling a business in which he who offers well and advertises still better gets most. Social spirit of any kind has disappeared from present-day medical activity, and physicians have become the slaves of capitalism, because there is no doubt that the benefits of medicine and hygiene are enjoyed only by those having much money. Most of our physicians still look upon medicine from the point of view of individual, and not from the point of view of social, practice....

From the etiological point of view bad housing is one of the major causes of disease.... Building rules should be fully obeyed in the smallest village, because we should take care of the tiniest cottage just as thoroughly as of a town palace.... State housing control is a necessary legal regulation which sooner or later will have to be introduced.... The task of this control is to study housing conditions, to eliminate unfavorable factors, and to introduce improvements, especially when the economically weaker are involved.... If we want to see our towns prosper in the near future, we must, at once, undertake all measures for securing the correct building of healthy houses, free from unscrupulous speculation....

Workers’ health protection... calls in this country for the implementation of important social and medico-political measures. Certain restrictions are necessary regarding working time, because the human organism, however perfect it may be, cannot work like an ordinary machine; while the faults of an ordinary machine can be repaired, parts of the human organism recover very slowly or do not recover at all, and must not be exploited at will. The demands for an eight-hour working time should be strongly supported and justified from the medical point of view....

The machine must not oust man from the workshop to make the capital invested in it pay higher dividends; it must help the worker, it must facilitate his work, and thus protect his health.... Technically facilitated and more advanced production must not benefit invested capital only, it should to a considerable extent be used for the improvement of working conditions –for the building of hygienic houses, the provision of good and cheap food, health education, etc.... The present time should give work its due, its dignity. The Government has allowed dead capital to drain it of its most valuable living capital—the human organism—for so many years, it must now allow the regeneration of this organism at the cost of dead capital.

Social insurance is usually considered as part of the workers’ question. Today it cannot remain within these restricted limits, it must develop into universal insurance.... In most countries, just as with us, the insurance scheme has existed only in the case of disease or accident. The present time requires general popular insurance in the case of disease, accident, unemployment, old age, infirmity, and poverty. We have to start tackling our social and health questions energetically and stop suffocating ourselves in pre-war mentality....

Great material sacrifices necessary for the implementation of our health programs could be alleviated by special health taxes. This taxation system should be independent of general financial policy and the means obtained must be used for health investments, mostly preventive in character.

1. A 2% tax on the direct tax to be paid by all tax-payers....
   
2. A rate of 2% of the net profit of the industrial establishments employing more than 50 workers and legally bound to make its accounts public; those not legally bound to it should pay 3%, and those involving work injurious to human health should pay 5%.
   
3. A rate of 5% of the net income of the firms engaged either in the production or sale of alcoholic drinks, unless they are taxed according to item 2, but if they should pay, in addition, the difference up to 5%.
   
4. A rate of 5% on the prices fixed for the monopolized tobacco sales.
   
5. A rate of 10% as the customs duty on luxurious objects.
   
6. A rate of 10% for the monopolized sales of alcohol.
   
7. A rate of 10% as a tax on the houses of those who live in these houses and have more than 5 rooms at their disposal, the rooms used for the carrying out of their profession being excluded....
   
8. A rate of 10% as a tax on luxurious houses (villas, castles, etc.) which are only occasionally used as residences, for instances for hunting, excursions, holidays, etc.
   
9. A rate of 5% of dividends obtained from shares held in various companies.
   
10. A rate of 10% on liqueurs, rum, cognac, absinth and champagne....
    

I have given an outline of the health program to be carried out in this country now in the post-war period. For the enormous and extremely urgent task we need not only a great many skilled experts but also even greater material sacrifices.... Physicians will not be allowed to remain in their hospitals, consulting rooms, and sterile offices—they will have to step into public life and fight for achieving an ideal—an appropriate health policy—and considering this policy as the most important part of general national political life....

Footnotes

Excerpted from Andrija Stampar. Jugoslavenska njiva. 1919;29–31:1–29. Republished in English in Grmek MD, ed. Serving the Cause of Public Health: Selected Papers of Andrija Stampar. Zagreb, Yugoslavia: Medical Faculty of the University of Zagreb; 1966:58–78.

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