disease has certain symptoms which are dealt with in certain ways according to certain rules which doctors know.

The patient's failure to understand the doctor's work may be almost as serious a limitation upon the efficiency of medical treatment as lack of skill in the doctor himself. Only the most patient, tactful, painstaking course of explanations and instructions can persuade an uneducated adult to take a disagreeable treatment or to change his occupation or many of his life habits, when the doctor believes that his health requires one or all of these things. The foreign born are by no means the only people who do not understand the principles of hygiene and the nature of disease; but certain points due to this lack of understanding are thrown into high light among them.

THE PROFESSIONAL LIMITATION

Many of the doctors, hospitals, and dispensaries accessible to the foreign born are on a low plane of efficiency. The nature of the private doctor's work with the foreign born, and the low income received, tend to draw into and retain in immigrant sections physicians who have not received the most recent or best medical training. Severe competition often prevails which puts a premium on commercial rather than on professional ability, and tends to lower rather than raise the standard of medical care.

Medical science has grown beyond the mastery of any one man and now requires specialization of skill. The conditions prevailing in immigrant districts practically limit the physicians who reside there or who do

most of the local work, to general practice. The population can usually gain access to the specialist only by going to hospitals or dispensaries as charity patients.

The practice of medicine once required the physician's personality, his brain, and his trained eye and hand, and only a few simple inexpensive instruments for diagnosis and treatment. The practice of medicine to-day requires an elaborate and expensive equipment-manifold instruments, X-ray apparatus-and extensive laboratory service, if the best diagnostic and therapeutic results are to be achieved. To conceive that such equipment could be available to every practitioner in his private office under his individual control is out of the question, nor could any one man learn to use all of it if he had it.

There are various exceptions to these general statements. Yet in the main they are true. The defect here is called a professional one, but the medical profession is less to be blamed for it than the community.

THE SOCIAL LIMITATION

The general public has failed to keep abreast of the development and possibilities of medical service. The practice of medicine now requires community aid if the physician is to have sufficient capital for equipment and sufficient facilities for working with specialists.

The organized practice of medicine appears in many hospitals and dispensaries where elaborate equipment is provided which many doctors can use, and where the different branches of professional skill are so

organized that teamwork and group medicine are facilitated. But thus far such organization has been only within the limits of institutions, to which a comparatively small number of physicians have access, even in large cities. Specialists are few in number, except in large cities, and high priced.

The work of the specialist and the institution is, as a rule, inaccessible to the immigrant on any but a charity or semicharity basis. The need of a community organization of medical service which shall be exclusive enough to provide the best facilities for medical care "to all the people who need them and all the doctors who know how to use them" is as yet nowhere realized.

We see the need of such community organization most strongly in the small city or town. In some industrial communities, for example, where from 50 per cent to 90 per cent of the population consists of foreign born and their children, there is only one hospital, and that hospital is chiefly for patients who can pay. There is usually no dispensary, and most important of all, only a very small proportion of the doctors of the town have access to a laboratory, an X-ray department, or to the consultation privileges of the hospital staff. There are few, if any, specialists in a small community, for there are rarely enough people to support a skilled oculist, a throat and ear specialist, an orthopedist, or a pediatricist.

In many large cities the sections thickly populated by immigrants suffer under the same conditions, but in the large city better facilities can be obtained by going to institutions or physicians in other sections. Only by a city-wide organization of medical service, with

institutions related to one another and to general medical practice, can such conditions in cities be remedied. Only by organization on a state-wide basis can the gross deficiencies of the small cities and towns be made good.

By what means shall the extent and quality of medical care among the immigrants be improved? Many of the characteristics of our present system of medical service, which militate against the immigrant, militate also against the native. A system must be developed which can give adequate service to all people of small means and little health knowledge. Given this fundamental improvement, farther adaptation to the needs of the foreign born will not be difficult. The peculiar terms of the immigrants' condition intensify every general difficulty, and also create special problems, but dealing with these is a matter of technique, the specialized application of sound general principles.

HEALTH INSURANCE

Health insurance is one measure proposed for improving the medical care received by the masses of the community. It is aimed particularly at the economic limitation. While it does not apply separately to the foreign born, its application would include them. Health insurance, as it has been most seriously discussed in this country, follows more or less the lines of the British and German systems. It is formulated most definitely in the so-called Model Bill of the American Association for Labor Legislation. The provisions of such a law require that all wage

earners or possibly only those up to a certain limit of income, or in certain occupations-be insured. Insurance groups are formed along local, occupational, or establishment lines. Existing fraternal or industrial societies can thus be recognized. The insured pay a portion of the expense, the employer a portion, and the state may also pay something, either directly or by meeting the overhead expenses of administering the system.

Various benefits are contemplated. Cash, amounting to one half wages, is given during the period of sickness up to twenty-six weeks in one year. In addition, medical care is provided the insured person. Bills which have been considered by some state legislatures give medical care to all members of the family. Some of the bills provide for dental and hospital care, and for nursing service; some for a maternity benefit; and most for a small cash benefit, not exceeding one hundred dollars, to cover the immediate funeral expenses of the insured person.

Such a scheme of health insurance obviously seeks to prevent the expense of sickness falling upon the individual with crushing force at the very time when he and his family are least able to bear it. The proportion of persons who are ill at any one time are cared for by the continued payments of those who are well. This is simply the application of familiar principles of insurance long established in other fields. The essential idea is to distribute the burden of a risk. The fundamental virtue of the proposal is that sickness is inherently an insurable risk, and that the burden ought to be distributed, not only for the sake of the suffering individual, but for the sake of the