Document 5DXVz5GYwpBRaRbLLO2RQXbZD

The Metropolitan Story The Health and Welfare Work of The Metropolitan Life Insurance Company, New York By LOUIS I. DUBLIN, Ph.D., Second Yiso-Prosldonf and Statittielan, Metropolitan Ufa Inturonco Company ittrlnltO Or toratniwi l Hcetth, Conada'a Nottanal Haatlk Mctazim N JANUARY 1909 an event of A fortunate chance meeting with I great significance occurred both for life insurance and for the the then chief officer of the Metropo litan, Haley Fiske, resulted in an public health. It was then that the invitation to put his ideas to work in Metropolitan Life Insurance Com an organization with millions of pany launched its program of life policyholders to be served. Never be conservation with Dr. Lee K. fore was a plan launched with as Frankel, a distinguished social work much enthusiasm. Dr. Frankel saw er, to direct it. This extraordinarily his work grow from year to year gifted man had for many years con until his untimely death in July cerned himself with the problem of 1931. He lived long enough, however poverty and its prevention. Sent by to see the campaign against unneces the Russell Sage Foundation in 1908 sary sickness and death developed to study the various systems of on a huge scale among an increasing sorial insurance which had develop number of industrial policyholders ed in Western Europe, he came back in the Metropolitan. He laid such to America with a wealth of ideas as solid foundations as to assure the to how life insurance, and particu continuation of the program with larly industrial life insurance, could equal enthusiasm after his death. become a force in the life of wage The benefits of his influence reached earning families. He saw in such far beyond and contributed to the insurance, not only a means for pro welfare of the people of the entire moting economic security, but also a American continent. powerful aid to advance the health of the insured. He had learned, as Public Health la 1909 the director of a relief agency, the Let us see what the condition of important role which disease and the public health was at the time of premature death play in the life of the launching of the Welfare Divi the industrial population. sion. Medical science had made ** great advances in the decades immediately prior. The establish ment of the germ theory by Pasteur was soon followed by the identifica tion of the causes of the more im portant Hiaftngftft such as tuberculosis, typhoid fever, diphtheria, and pneu monia. The important role of insects in the spread of disease had been shown. Surgery was progressing rapidly. The potentialities of public health efforts had been spectacu larly demonstrated by the trans formation of the Panama Canal Zone from a "white man's grave'' to a healthy district. Health officers everywhere were learning that it was possible to control disease. Nevertheless, there were wide gaps between what was known of preventive medicine and the actual state of the public health. Tuber culosis was very common among the working class families. The infect ious diseases of children were wide spread, and together with infantile diarrhea, accounted for a huge loss of child life. Maternal mortality was high. These and other factors made the time ripe for a widespread attack on public health problems. It is significant that a business organiza tion should have felt the urge to con tribute toward their solution. Through its large network of Dis trict Offices in Canada and the United States, and its field men, the company had facilities for reaching a great number of people. It had a financial stake in better public health. It was motivated also by a high ideal of service as expressed by Mr. Fiske when he informed the policyholders about the new Welfare Division with these words: "Today the Metropolitan is launched upon a new era--an era in Which it joins the forces in battle against disease, and in which it hopes to lead the world in preserving lives from the ravages of mankind's insidious foes.'' Dr. Frankel's first step in the company's health campaign was to plan and create a number of health pamphlets. They were designed pri marily for mothers in industrial families and were, therefore, simply and attractively written. The first of the series was called "War on Con sumption." This was the first job in my service with the company. This pamphlet, under steady revision, has reached the amazing total of nearly 34 million copies. Another early publication which had great success was the beautifully illustrat ed "The Child.'' Later, there ap peared various leaflets, each con cerned with one of the commoner communicable diseases. As the years passed, new pamphlets were added until they constituted a well balanc ed and popular library on the every day problems of health which be came a guide to health in the homes of millions of people in the United States and Canada. It should be pointed out that even in those early days the company al ready had about 10,000 agents who enjoyed friendly and regular con tacts, often weekly, with millions of policyholders. These men had the unique opportunity to spread health knowledge, and they became the backbone of the company's health education program. It is also im portant to record that as these pamphletB became available they were sought by health officers and school authorities everywhere be cause of their attractiveness, their simplicity, and their authority. As a result, their circulation grew by leaps and bounds, and over the 40odd years the total circulation of the company's health literature has readied a billion and a half copies. Last year alone more than 33 million publications were distributed. It would be very difficult indeed to estimate the total effect of this single step in educating the Ameri can and Canadian people in the facts of personal and community hygiene. Equally important was the next 4 .-4 move in the health program which Dr. Frankel launched. 11118 was to make available a bedside nursing service to the industrial policy holders of the company without charge to them. This step was taken at the suggestion of Miss Lillian D. Wald, then head of New York City's famous Henry Street Settle ment. On June 9, 1909, the first Henry Street public health nurse visited a sick policyholder. The first moves were tentative and were limited to a trial period of three months in one section of Manhattan. The service proved so valuable it was Boon extended throughout the city. Managers, agents, arid policy holders in other places, hearing of the service, were soon asking urgent ly for similar arrangements, and, by the end of the year, bedside nursing had been extended to five more cities in the United States. Early in 1910, Metropolitan nursing serv ice was extended to Montreal. This was the first affiliation with the Victorian Order of Nurses, which has conducted the Metropolitan's nursing work for English-speaking policyholders in Canada for more than 40 years. It was an example of Frankel's genius for wise derisions that from the beginning the company adopted the policy of affiliating with existing ' public health nursing organizations wherever they performed a good pro fessional job. Where such associa tions were lacking to meet the de mand of policyholders for nursing. Dr. Frankel and his associates help ed citizen groups to establish local organizations. I can well recall that Dr. Frankel would be away for weeks at a time addressing interest ed leaders in various Communities on the necessity of organizing such serv ices, holding out the promise of affiliation with the company which would help in financing the service. In this way, Dr. Frankel helped to spread public health nursing which now covers the length and breadth of the United States and Canada. But his influence extended beyond financial help. From the beginning he pointed out that in addition to good bedside nursing it was neces sary to have adequate nursing re cords, adequate supervision, and simple and accurate accounting systems. Wherever the affiliation was made, the policyholders of the company, the local nursing organi zation and the people at large bene fited from it. I believe that in the list of Dr. Frankel's contributions to American public health, the effec tiveness of public health nursing in the United States and Canada today is his chief monument. Early in the welfare program, the company found it necessary to organize a staff of Metropolitan salaried nurses to serve communities which had no visiting nurse agencies or where no such voluntary agency could be readily established. Thus, a Metropolitan nurse was appointed in St. Paul, Minnesota, in 1910. In the following year the first salaried nurse was engaged in Toronto. As the years passed, the services grew in number--both by affiliation and by Metropolitan salaried stafb. At the height of this development, more than 7,000 cities and towns in Cana da and the United States were served, and in the course of the 42 years more than 105,000,000 visits have been made to almost 20,000000 Bick people, at a cost to the com pany of over $105,000,000. The changing needs of the times have influenced the direction and content of the nursing service. The main emphasis from the beginning has been on skilled bedside care for acute illness and maternity care for women before and after childbirth. But with the years, health teaching became as much a part of the Me tropolitan nurse's work as was nursing care. Such teaching has in cluded how to avoid the spread of infection, how to plan for better nutrition, and how to prevent acci dents. Thenurse's knowledgeof com munity resources has often helped families under her care to obtain necessary treatment or other serv ice. In emergencies and disaster, Metropolitan nurses have always been among the first to offer aid. The company's records in Canada and the United States contain many reports covering such emergencies with statements like these: "On duty practically 24 hours every day". . ."I gave 1,500 inoculations against typhoid". . ."No doctor to help me, .but an accurate check shows that most of my patients are safe." From the beginning, the company spared no effort to keep standards for the service at a high level. Only well-trained, professionally qualified nurses were employed. They were encouraged to keep up with develop ments in their field by a staff education program and by companysponsored scholarships for post grad uate public health nursing study. The Metropolitan has not only encouraged additional training for its own nurses, but has often joined with other interested agencies to sponsor projects for the improve ment of public health nursing as a whole. In Canada, for example, to meet the pressing need for qualified French-speaking nurses, the com pany helped to finance a public health nursing course at Montreal University. In cooperation with the National Organization for Public Health Nursing, the Metropolitan prepared a Manual of Instructions for Public Health Nurses. The com pany has made many studies which have stimulated better all-round performances by nursing agencies. An important Metropolitan con tribution has been the development of accurate nursing records. These data have helped nursing agencies to operate on sound business princi ples. They have also helped in deter mining how nursing service could best serve the needs of the com munity, and some studies have proved to be valuable material in medical and public health research. Growth of Public Health Nursing The company's financial support in paying for visits to policyholders has also greatly influenced the growth of public health nursing organizations in Canada and the United States, particularly in the earlier days. Many of the newer nursing agencies now available to the general public were founded because of Metropolitan's encour agement and financing. In 1950, after 41 years, the com pany felt that the value and per manence of public health nursing was well established all over the United States and Canada and that the time had come for the company to direct its main public health effort into new and unexplored channels. To provide a period of adjustment, the company, on June 30,1950, announced its plans to ter minate its Nursing Service as of January 1, 1953. In the meanwhile the company is concentrating its efforts to help organize visiting nurse associations where none exist and to help strengthen others. This outcome was foreseen even in the beginning; Dr. Frankel told Metro politan nurses on many occasions: ,rWe must all cooperate in order to work, ourselves out of a job; then we shall know that our efforts have been constructive and results accomplish ed." Public health nursing has been called the greatest contribution of America.to public health achieve ment in the 20th century. The Metropolitan can well be proud of having played an important part in the development of this movement. Supplementing the health pamph lets and the friendly advices of the nurses and agents, the company has over the years developed a number of other media in its program of health education. Of prime im portance has been the long series of health films. In 1924, the com pany's first film, "One Scar or Many" was prepared and distribut ed. It played an important role in pointing up the necessity for univer sal vaccination as a preventive of smallpox. A long series of profession ally prepared films followed, dealing interestingly with such health prob lems as street and highway safety, diphtheria immunization, nutrition, heart disease, and overweight. They have enjoyed a remarkable success, having been shown in theatres and other public places, and now on television, throughout Canada and the United States to audienoes total ling more than 160 million people. A new color film on weight control, "Losing to Win", will soon be re leased. The Metropolitan has also devel oped a unique advertising program in the national magazines which over many years has brought im portant health messages to millions of readers in Canada and the United States. These advertisements appear monthly and cover a wide range of topics, but in a general way three themes have been stressed: the im portance ofkeeping fit; the danger of neglecting even minor illnesses and injuries; and the benefits of periodic medical examinations. In recent years, the company has geared many of its advertisements to sup port the campaigns of the great national voluntary health agencies, such as the National Tuberculosis Association, the American Cancer Society, etc. The company has also launched a similar program on national radio hook-ups. Each of these broadcasts mentions a particu lar booklet in the company's health library which listeners are invited to send for. Fifty thousand requests for such booklets have been received in a single month. One of the most dramatic and effective tools for advancing public health has been the local health demonstration. Through this device the attention of an entire continent can be focused on one community, which serves aa a proving ground for demonstrating the efficiency of pub lic health measures. The com pany's first major undertaking of this type was carried on in Framing ham, Maas., between 1916 and 1923. The 17,000 citizens of the town and the National Tuberculosis Associa tion joined the company in demon strating how a typical American community could bring the under control. Fortunately, this effort was under the able leadership of Dr. Donald B. Armstrong, who directed the experiment throughout the entire period. By the end of the seven year period, the tuberculosis death rate in Framingham had been cut 68 percent. But the improve ment in the health of this com munity was not limited to tubercu losis. There was also a sharp de crease in infant mortality and in the general death rate. Fortunately, Framingham learned that public health work was thoroughly practi cal and worthwhile. The services, supported by the Metropolitan during the period of the demonstra tion, were taken over by the com munity itself and have, in fact, been augmented over the years. Today, Framingham has succeeded in bring ing its death rate from all of the infections to extremely low levels. It has also enjoyed the distinction of having shown to other American communities 'How1 similar results could be obtained, provided the necessary organization and resources were put to work;5 Thetford Mines, Quebec, was the scene of another far-reaching dem onstration. This community was chosen at the suggestion of an offida1  of the Church because of the high infant and maternal death rate, and the substandard health conditions existing there. The demonstration lasted from 1921 to 1924, and re ceived the enthusiastic support of the town officials, the clergy and the medical profession. During the threeyear period, the infant mortality rate had dropped from about 300 per 1,000 to 96 per 1,000, a reduc tion of 68 percent. The community of Thetford Mines carried on the work after the demon stration ended, but its influence was much more far reaching. The pro vincial government of Quebec was so impressed by the effectiveness of this demonstration that it appro priated $500,000 for similar efforts throughout the whole province. The province has since taken step after step to further public health work. It has established health units throughout the province, has sent promising young physicians to the Schools of Public Health in the United States and in Toronto for special training, has encouraged the training of public health nurses and has in every way moved forward to establish an effective health service for the people. The Metropolitan's health and welfare work throughout the years has been carried on in cooperation with other groups, official and voluntary, working toward better public health and safety. Health de partments, medical societies, par ents' associations, school admini strators, and dozens of other groups have been active participants in Metropolitan campaigns.These have been directed at varioustimes against tuberculosis, diphtheria, typhoid fever, influenza and pneumonia, appendicitis, accidents rheumatic fever and heart disease. Aid te Medical Research Through its Welfare Division, the Metropolitan has also conducted or given financial support to much im portant medical research. An out standing example is the work of its Influenza-Pneumonia Commission, established in 1919. This commis sion of leading scientists, financed by the company, helped greatly to develop pneumonia sera, at one time the only weapon against pneumonia, and later contributed to the wide use of the sulfa drugs and antibiotics which have helped to bring pneu monia under control. Since 1930, the Metropolitan has cooperated with Dr. Elliott P. Joslin and his associ ates at the George F. Baker Clinic in Boston, Maas., in an intensive study of diabetes and in spreading knowledge on how to control the diitPftBfi Recognition of the tremendous value of coordinated research finally led to the establishment in 1945 of the Life Insurance Medical Research Fund supported by some 149 life insurance companies in Canada and the United States, including the Metropolitan. Through this pro gram, about $600,000 is granted annually for long-term research pro jects. Currently, the emphasis is on diseases of the heart and allied conditions, which are now the fore most cause of death in North America. The fund is supervised by a board of directors composed of company presidents and an advi sory council of distinguished physi cians. The company for many years has had an active interest in the field of industrial hygiene. The growth of group insurance has stimulated these activities. Since 1916, the Metropolitan has had an industrial hygiene service which works with employers to solve health problems in their particular industries.Studies have been made of silicosis, asbestosis, and hazards in the ceramic, leather, and other industries in Canada and the United States. These studies have not only meant life-saving service to group policy* holders, but have also been used by health officers and others in the field of preventive medicine. The Statistical Bureau was launched early as an arm of the Welfare Division. Dr. Frankel con sidered accurate record-keeping and sound analysis of the experience essential to his program. The first function of the bureau was to study intensively the mortality experience of the company's policyholders and to determine the opportunities for service by the Welfare Division to prevent unnecessary sickness and death. Later, the Statistical Bureau expanded is functions in connection with the many business activities of the company, including the study of hazards of occupation, and the risks involved in certain types of physical impairment. In this way, the bureau has served as a bridge between the welfare activities on the one hand and the business opera tions of the company on the other. The bureau's records have proved a rich mine of information on the health and longevity of the Amer ican people. Mud} statistical re search has been conducted for the guidance of health officers and private agencies engaged in public welfare service. Every important phase of public health has been covered, but emphasis has been placed especially on tuberculosis, infant mortality, children's diseases, maternal mortality, cancer, diabetes and heart diagum and allied condi tions. The bureau has cooperated with health officers and registrars all over the country to improve birth and death registration It has also served as a consultant to many health officers, registrars, directors of nursing services, and other pri vate health organizations, in the preparation of their reports and in the organization of their research work. It is obviously impossible in this brief sketch to cover the wide range of activities which were initiated by the company under its health and welfare program. I have attempted here to touch only the high spots of this operation, and more particular ly those which would be of particu lar interest to Canadian readers. Enough has already been recounted to indicate the scope of this activity. It will now be of interest to see, at the close of 42 years, what has been the effect of the Metropolitan's health conservation program on the life of the company's industrial policyholders. This is, after all, the add test of the wisdom and worthwhileness of the plans which were carried on over the years at considerable cost to the company. Perhaps the best single measure of the results is in terms of life expecta tion. In 1911, at the time the Wel fare Division was launched, indus trial policyholders had a life expect ancy at birth of 46.6 years. By 1950, that figure had risen to 68.21 years. The gain in the past four decades thus amounts to more than 21H years. At the beginning of the experiment, the average length of life for industrial policyholders was 6H years below the average for the population. Today, the averages for the two groups are practically the same. This is the measure of what has been achieved. Interest also centers in some oif the details of this achievement. The mortality rate has declined almost continuously over the period and has now reached the extremely low figure of 6.37 deaths per 1,000 policyholders, which is practically half the death rate of 12.53 per 1,000 recorded in 1911. Under the mortal ity then prevailing, the mean num ber of industrial policyholders in 1950 would have experienced 300,000 deaths in place of the 119,000 which were actually recorded. This repre sents a saving of 181,000 lives in one a e-.n.vi year alone. Such is the nature of this accomplishment. The value and the effectiveness of the program are further indicated by the very striking reductions in mortality from specific causes. Thus, tuberculosis has been reduced 91 percent, pneumonia and influenza 87 percent, the communicable diseases of childhood 99 percent, syphilis 55 percent, and accidents more than 50 percent. It is in these areas that our efforts have been concentrated, and it is here that the greatest gains have been achieved. Similar progress has been made in reducing mortality among Canadian policyholders during the past four decades. Even during the last 20 years the death rate in this insured group has declined 40 percent. 'Hie success achieved against some items in the mortality picture is nothing short of spectacular. For example, diarrhea and enteritis two decades ago woe leading causes of death in some of the provinces. In 1931, the rate was about as high as that for pneumonia or cancer. The deathrate from diarrhea and enteritis has since been reduced 90 percent. In the same period, the mortality from typhoid fever and other conditions prevalent in parts of Canada have been practically eliminated. Perhaps the most striking demonstration of the development of good public health service in Canada is offered by the marked improvement in the mortality of French-Canadian poli cyholders. In the 1920's, there was a considerable difference in the death rates of policyholders in Quebec and in Ontario. As the years passed, this divergence was continuously re duced, and now there is very little, if any, difference in the rates for the two provinces. Here again we see the direct effect of concentrated effort by voluntary and official agencies to control the preventable causes of mortality. These extraordinary gains reflect the character of men and women who have directed the company's welfare activities. It was indeed a fortunate circumstance which brought Lee K. Frankel into the field of life insurance at the particu lar time when his genius and re sourcefulness were so much needed. On his death in 1931, the company turned to his colleague. Dr. Donald B. Armstrong, who had made a reputation for himself as the director of the Framingham Demonstration, to carry on the administrative work of the Welfare Division with which he had been associated since the discontinuance of that demonstra tion in 1923. How well the mantle fitted is best indicated by the continued progress of the division and by the high esteem in which he is held by the entire medical and public health profession. Dr. Arm strong, I am confident, will wish to share this esteem and recognition with the fine group of associates he has had in the administration of the many activities of the company's health and welfare work. Under his direction, the company's resources for health conservation will continue to be applied to old and new prob lems to the best advantage of the policyholders and the people at large. v PtfNTfD IN CANADA