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I. The reduction of sickness and the promotion of mental and bodily vigor through community or organized preventive methods of proven effectiveness. These are essential public health services.

II. The provision through government funds of certain kinds of public medical facilities and services, to the entire population, and of general medical services to indigent and dependent individuals and families.

III. Insurance against wage-loss due to illness.

IV. Insurance against the costs of medical care.

The two latter measures are based upon the principle of distributing costs over periods of time and among groups of individuals of that fraction of the population which is financially unable to budget individually against such costs. This procedure is ordinarily termed "health insurance" or "sickness insurance".

In this report we discuss briefly the principal aspects of the problem of economic insecurity arising out of ill health. On certain phases, our studies enable us only to call attention to the importance of not neglecting these aspects of the problem and to give endorsement to measures and policies which have been or should be worked out in detail by other agencies of the Government. On other phases we have specific recommendations to make. In general, however, we wish to present a program which not only is a part of a broad plan for dealing with the problem of economic security, but which is also, in itself, a program for the maintenance and promotion of the public health.

B. PUBLIC HEALTH SERVICES

As stated by the medical advisory board of this committee, in a brief progress report recently filed with our staff:

"A logical step in dealing with the risks and losses of sickness is to begin by preventing sickness so far as is possible."

Much progress has been made in this respect, yet the fact remains that despite great advances in medicine and public-health protection, millions of our people are suffering from diseases and thousands die annually from causes that are preventable. The mortality of adults of middle and older ages has not been appreciably diminished. With the changing age composition of our population the task of health conservation must be broadened to include adults as well as children. Even minimum public-health facilities and services do not now exist in many large areas. Of 3,000 counties, only 528 have full-time health supervision and only 21 per cent of the local health departments were rated in 1933 as having developed a personnel and service providing a satisfactory minimum for the population and the existing problems.

Evidence is accumulating that the health of a large proportion of the population is being affected unfavorably by the depression. The rate of disabling sickness in 1933 among families which had suffered the most severe decline in income during the period 1929 to 1932 was 50 per cent higher than the rate in families whose incomes were not reduced. For the first time in many decades the annual death rate in our large cities has increased, the rate in 1934 being higher than in 1933 despite the absence of any serious epidemics. In the face of these evidences of increased need local appropriations for public health have been decreased on the average by 20 per cent since 1930. The average per capita expenditures from tax funds for public health in 77 cities in 1934 were 58 cents as contrasted with 71 cents in 1931. It is not too much to say that in many parts of the country the men and women in public-health work are very discouraged* In this situation there is great need for a Nation-wide program for the extension of preventive public-health services. As was well stated by the medical advisory board:

"At the present time appropriations for public-health work are insufficient in many communities, whereas a fuller application of modern preventive medicine, made possible by larger public appropriations, would not only relieve such suffering but would also prove an actual financial economy. Federal funds, expended through the several States, in association with their own State and local public-health expenditures, are, in our opinion, necessary to accomplish these purposes and we recommend that substantial grants be made." In accord with these principles and following the specific suggestions of the Advisory Committee on Public Health. we recommend: (1) Grants-in-aid to local areas unable to finance public-health programs with State and local resources, to be allocated through State departments of health; (2) direct aid to States in the development of State health services and the training of personnel for State and local health work; (3) additional personnel within the United States Public Health Service for the investigation of disease and sanitary problems which are of interstate or national interest and the detailing of personnel to other Federal bureaus and to States and localities, The Advisory Committee on Public Health suggested that in order to carry out these policies the total appropriation to the Public Health Service be increased by $10,000,000 per year, in contrast with $5,000,000 -- 4 cents per capita -- now spent by the Federal government in all its departments for human health services. The advisory committee also reported that the needs of the country are considerably in excess of the additional expenditures suggested but expressed the view that a larger amount cannot be efficiently spent until necessary additional personnel has been trained and further tests of practical procedures have been made through which certain diseases can be more effectively controlled. It is not within our province to say whether the precise amount suggested should be appropriated, but we strongly endorse the recommendation for increased Federal participation in the prevention of ill health.