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An Address ON INTERNATIONAL STANDARDS OF PUBLIC HEALTH AND WELFARE WORK,
OCTOBER 25, 1919. Every tuberculosis
An Address ON
INTERNATIONAL STANDARDS OF PUBLIC HEALTH AND WELFARE WORK, Delivered before the British National Association for the Prevention of
Consumption, London,
BY WILLIAM CHARLES
sanatorium provides for but one social If an attempt is made to inject another, the troubles within the institution multiply steadily. Such limitations restrict the use of most of the equipment which we at present have at our disposal to handle the tuberculosis problem. In proposing to you certain essentials of international standards, my object is to render effective the work of all our organisations against tuberculosis-in other words, to fit the equipment to the task to be done.
group.
Oct.
16th, 1919,
WHITE,
MEDICAL DIRECTOR OF THE TUBERCULOSIS LEAGUE OF PITTSBURGH.
MR. PRESIDENT AND GENTLEMEN.-Great Britain and America are both interested in establishing an international standard of public health and welfare work, and though their reasons for this interest differ, both must fully cooperate if it is to be established throughout the world. The British Empire is composed of greatly varying national groups. Its colonies are widely separated by land and Its government has learned the great lesson of sea. releasing power and establishing local autonomy with central
supervision. The United States, on the other hand, starting with individual states which possessed complete local autonomy, has adopted in the last half century a policy of highly centralised Federal power which exerts an ever-growing control over the enormous territory and wealth enclosed within its compact borders. This is the more striking, in that often in the smallest governmental unit, the industrial municipality, as many as 50 different nationalities are represented in segregated national groups. In other words, the problem for the British Empire and the United States is the same in that each, as a matter of government, must deal with many different races and nationalities, but in the former federation the units are scattered over the earth, separated by ocean and alien land, while in the latter, they are divided only by the imaginary line of state or county. A comparison of these two great federations does not come within the scope of this paper, save as it throws light upon the solution of the enormous problem of human welfare, which forms the greatest business of any government.
THE EQUIPMENT MUST BE FITTED TO THE TASK. The equipment must be modified to meet the requirements of each locality. This obviously suggests that, in order to make a proper adjustment, it is first necessary to take careful stock of each region to be handled and to find out exactly the specific task to be performed. In mappttg out a programme, I should put in the place of first importance this careful stock-taking, examination, and statistical record of the kingdom, district by district. On its completion I should determine, on the basis of the relative values of equipment, just what the budget for each district could stand in successive periods, and in what direction its funds could best be
expended. Let us look for the moment at the question of these relative values. Approximately 85 per cent. of our tuberculosis population will always be cared for in the home. The remaining 15 per cent. may for the moment be disregarded, while domiciliary care thus becomes the dominant factor in determining the relative values of equipment, 85 per cent. of which must be devoted to this large proportion of our population. What agency have we to meet this heavy demand ? Rating our entire equipment at 100 per cent., values varying from 25 per cent. to 60 per cent. have been placed upon the public health nurse or public health visitor. Personally I estimate her value at 60 per cent. or higher. The field of activity which she has finally appropriated is one which no other agent is able to cover, for it is educational in character. She educates the family to carry out the advice of physician, economist, and sanitary officer. This leads us directly to the question of the working unit for public health work. For this I should choose a public health nurse and that amount of territory and number of people whom she can adequately handle. With such units established for each group of population, the rest of the programme would require, in diminishing ratio, an equipment of dispensaries, laboratories, hospitals for advanced cases, and sanatoriums, with physicians and consultant nurses to correlate them properly and to bring them into harmony with each other in one composite whole.
FOR LAYING DOWN STANDARDS. this phase of the question for the moment, let us Leaving attempt to fix a basis for international standards for public health and welfare work. We must first determine EFFORT MUST BE COORDINATED. our essentials, their relative value, and, on the basis of the Our second essential, then, which may be described as budget available, where the greatest returns from expenditure will be gained ; secondly, we must establish our build- coordinated effort, depends upon the great principle in tubering stoue, our working unit ; finally, we must correlate culosis work which Sir Robert Philip has given to the world these units into a composite whole. and which stands next in relative value to the implements Tuberculosis, as a problem, has taken a prominent place which we have already described. in the formulation of our programme of health. If we had For example, in the fight against tuberculosis we might a specific cure for this malady, much that is now roughlv estimate that for every 250,000 of population we necessary in the campaign would pass into history. It is should need, in our poorer districts, 20 visiting nurses, one because we have no specific cure and must rely upon dispensary, with four or more sub-stations, hospital beds organisation and coordinated effort that it holds its equal in number to the mortality rate, five physicians, five consultant nurses, and a sanitary administrative office to important position at the present time. In the past each country has been guilty of putting an handle hospital admissions, open-air schools, statistics, an It would also be the function exaggerated value upon details which, from time to time, educational campaign, &c. have been suggested and advertised as a means of con- of one section of this office to establish and maintain controlling the malady. You all know them-sanatoria, hos- stant cooperation with those organisations dealing with pitals for advanced cases, dispensaries, mountain colonies, related problems, such as child and maternity welfare, farm colonies, and villages. medical examination of school children, infectious and The great weakness in each one of these if over-emphasised venereal diseases. Through its influence, for instance, a is that it represents but one. detail of a big scheme, and housing programme would be made to include suitable prooften is contrary to higher laws influencing the human vision for that portion of the population suffering from family. For example, infection with the tubercle bacillus tuberculosis which must be cared for at home. At least may at no period be taken as a just ground for a type of 5 per cent. of any,housing programme should be so arranged segregation which does not take account of social, educa- as to isolate and care for tuberculous patients in a household. Such factors of limited and very special use as farm and tional, and financial distinctions. Infection with the tubercle bacillus will not make the lion and the lamb lie down together. mountain colonies would be left to the various private groups, It it could do so many of the problems of the world would which would determine their position in the general probe solved. If it could do so we need now only infect gramme. These institutions would be placed in such relation Italian and Jugo-Slav, infect President Wilson and his to the whole problem as to care for suitable cases for a senate, infect the Bolsheviks, the Irish and the labour given district. Naturally their scope is limited, but the unions, in order to settle many difficulties between groups extent of the region each would serve would be determined of the human familv. by the number of available cases. No. 5017.
THE BASIS
-
DR. A. E.
720
BARCLAY :
IDEALS IN RADIOLOGY AND ELECTROLOGY.
THE RELATION OF CENTRAL TO LOCAL GOVERNMENT. We come next to the problem of the relation of these unit! to central government. If I were to suggest to you in Grea! Britain that there was any relation between the loss of th< American Colonies and your low death-rate from tuber culosis, you would probably laugh me out of court. Ye1 as I study the various speeches outlining your colonia: policy which have been made in your Parliament since thaI loss, I see a different trend given to your statesmanship from that period. As I read also the story of Baron Stein’s appreciation of your municipal and county autonomy which be carried back to Germany as the basis of its policy in forming its new empire after the Peace of Tilsit, I think I can see a definite relation between the thought generated by the loss of American territory and all that has since happened to the British Empire. It may be summed up thus : That your statesmen first learned to release power and have been the fathers in the world of local autonomy. This great principle, I believe, must be grasped by all those interested in every phase of the government of the world. Similarly, the release of power by the central authorities to local authorities, thereby enabling them to adjust equipment in health and welfare and educational matters to the task to be done in their respective localities, is the secret of control of most of our health and welfare
problems. The function, then, of central authority is correlate, suggest, stimulate, and subsidise, and
study,
to
so secure
equable and uniform establishment of standards throughout its kingdom. It will not do, however, to stop at your kingdom or our republic. To set up uniform standards throughout the world is the great privilege and duty of Great Britain, These standards have a America, France, and Italy. special significance for you in your colonies and also for us in America, because we have opened our doors to all the nations under heaven. Had we taken steps to secure uniform methods of health and welfare education and cooperation 50 years ago, we should not now be dealing with the serious problem of foreign groups segregated within the borders of nearly all of our industrial communities.
Address An [ABRIDGED] ON
IDEALS
IN RADIOLOGY AND ELECTROLOGY.
Presidential Address delivered before the Section of ElectroTherapeutics of the Royal Society of Medicine on Oct. 17th, 1919,
BY
ALFRED
HON. MEDICAL
E. BARCLAY,
M.D. CAMB.,
OFFICER, RADIOLOGY AND ELECTRICAL DEPARTMENTS, ROYAL INFIRMARY, MANCHESTER.
LADIES AND GENTLEMEN,—It is a time-honoured custom that the incoming President should address vou on some subject of his choice, and it is with much diffidence that I undertake the task, for I feel very deeply the honour you have done me and the grave responsibilities that are implied. The war has brought into prominence the wide fields that are open for the uses of electricity and other physical forces in medicine, particularly of X rays, with the result that many men are prospecting with a view to taking up the work represented by this section. For instance, in my own city five men are now established in X ray work where formerly there were but two, and I understand that this is more or less the same in all the large towns. I thought, therefore, that it might be of value if I addressed myself particularly to those men who, knowing only the military side of our arts, should know what the future holds if they are to become successful practitioners.
THE NECESSITY FOR TECHNICAL KNOWLEDGE. Whatever view we take of the future possibilities of our branch the present is with us, and one need hardly point out how vast are our opportunities-opening out in so many directions that no one worker can be a master of them all; what a change from 20 years ago, when in a few weeks a man could make himself as competent on the medical side of the subject as was possible. To-day it is a different story, and SUMMARY. to take his place a man must be prepared to master a of subjects such as are necessary in no other branch. chief a are careful of diversity then, first, My suggestions, analysis each region ; second, the establishment of a building unit Of course, it is essential that a man taking up this line of of public health nurse and her territory ; third, the correla- work should know his physics and electricity and all the tion of these on the basis of the Edinburgh principle, with technical work in radiography, radiotherapy, electro-therapy, the added superstructure of other equipment as budget &c., which are carried out for him by lay assistants. He will and necessity permit, but always on the basis of adapta- have to be responsible for the work of his department, and no tion to the region to be handled. To push these standards man is fit to do this who does not know the general principles throughout the world will require constant modifications and the detail of every job that is carried out for him by his based upon a knowledge of language and of the origin and assistants. This argues that he should also know the construction of his apparatus and the theory on which it is conformer condition of the people to be cared for. As a step toward obtaining such knowledge, we have been structed, for it is for him to say what is, and what is not, i able to
international possible
in a small wav a number of in Public Health Nursing. In this we hope the British Empire will join us, so that we may have travelling back and forth between the peoples of the world who differ in language and custom those agents of public health and welfare who mean most in the education of a populace-by teaching them how to carry out the suggestions for their betterment made by physician or other officer. I I have purposely not gone into the other fields associated with tuberculosis, because I believe with a proper building unit once established the correlation and addition of the superstructure is comparatively easy. It should not be difficult, even for an international plan, which on its completion will make it as safe to live in one part of the world as in another, for then in each region the equipment will fit the task, and the task will be outlined according to the first-hand facts and data furnished by each public health nurse for her special district.
begin
scholarships
.
THE
first
meeting
of
the
Lancashire
and
Westmorland Tuberculosis Society will be held on Thursday next, Oct. 30th, at 3 P.M., in the Houldsworth Hall, Deansgate, Manchester, when Dr. G. Lissant Cox, central tuberculosis officer to the Lancashire County Council, will deliver the presidential address. The attendance of medical men interested in tuberculosis is invited.
with the apparatus at his disposal. In short, he must be the master and must be able to talk to his
and any other assistant, and And these things faults in their technique. are outside and introductory to the science and art of medicine, of diagnosis and healing by physical means. The man who takes up this branch must be prepared to master these subjects if he is to approach his specialty from a scientific point of view. The man who by turning on a switch produces such and such a result is as empiric a physician as those of a hundred years ago who loaded a bottle with many different drugs in the hope that some one of the constituents would be of value. He did not know how or why he obtained his result, but at that time the knowledge was not available. To-day the man who fails to know the A B 0 of the science in which he deals is nothing less than a quack, and presumably a lazy one, .for the knowledge is ready to I admit that, at the hand to any man who cares to learn. moment, the knowledge is scattered and has to be sought out, but the establishment of the Diploma at Cambridge, with its very sound syllabus, ensures courses of study where all may obtain the requisite training.
radiographer, photographer, correct
SPECIALISED TEACHING.
importance of specialised teaching for our patent, especially to those of us who had
The is
way into it, the equipment
ur
own
for,
or
branch
to find not knowing what we were in of medical knowledge necessary;
An Address ON
INTERNATIONAL STANDARDS OF PUBLIC HEALTH AND WELFARE WORK, Delivered before the British National Association for the Prevention of
Consumption, London,
BY WILLIAM CHARLES
sanatorium provides for but one social If an attempt is made to inject another, the troubles within the institution multiply steadily. Such limitations restrict the use of most of the equipment which we at present have at our disposal to handle the tuberculosis problem. In proposing to you certain essentials of international standards, my object is to render effective the work of all our organisations against tuberculosis-in other words, to fit the equipment to the task to be done.
group.
Oct.
16th, 1919,
WHITE,
MEDICAL DIRECTOR OF THE TUBERCULOSIS LEAGUE OF PITTSBURGH.
MR. PRESIDENT AND GENTLEMEN.-Great Britain and America are both interested in establishing an international standard of public health and welfare work, and though their reasons for this interest differ, both must fully cooperate if it is to be established throughout the world. The British Empire is composed of greatly varying national groups. Its colonies are widely separated by land and Its government has learned the great lesson of sea. releasing power and establishing local autonomy with central
supervision. The United States, on the other hand, starting with individual states which possessed complete local autonomy, has adopted in the last half century a policy of highly centralised Federal power which exerts an ever-growing control over the enormous territory and wealth enclosed within its compact borders. This is the more striking, in that often in the smallest governmental unit, the industrial municipality, as many as 50 different nationalities are represented in segregated national groups. In other words, the problem for the British Empire and the United States is the same in that each, as a matter of government, must deal with many different races and nationalities, but in the former federation the units are scattered over the earth, separated by ocean and alien land, while in the latter, they are divided only by the imaginary line of state or county. A comparison of these two great federations does not come within the scope of this paper, save as it throws light upon the solution of the enormous problem of human welfare, which forms the greatest business of any government.
THE EQUIPMENT MUST BE FITTED TO THE TASK. The equipment must be modified to meet the requirements of each locality. This obviously suggests that, in order to make a proper adjustment, it is first necessary to take careful stock of each region to be handled and to find out exactly the specific task to be performed. In mappttg out a programme, I should put in the place of first importance this careful stock-taking, examination, and statistical record of the kingdom, district by district. On its completion I should determine, on the basis of the relative values of equipment, just what the budget for each district could stand in successive periods, and in what direction its funds could best be
expended. Let us look for the moment at the question of these relative values. Approximately 85 per cent. of our tuberculosis population will always be cared for in the home. The remaining 15 per cent. may for the moment be disregarded, while domiciliary care thus becomes the dominant factor in determining the relative values of equipment, 85 per cent. of which must be devoted to this large proportion of our population. What agency have we to meet this heavy demand ? Rating our entire equipment at 100 per cent., values varying from 25 per cent. to 60 per cent. have been placed upon the public health nurse or public health visitor. Personally I estimate her value at 60 per cent. or higher. The field of activity which she has finally appropriated is one which no other agent is able to cover, for it is educational in character. She educates the family to carry out the advice of physician, economist, and sanitary officer. This leads us directly to the question of the working unit for public health work. For this I should choose a public health nurse and that amount of territory and number of people whom she can adequately handle. With such units established for each group of population, the rest of the programme would require, in diminishing ratio, an equipment of dispensaries, laboratories, hospitals for advanced cases, and sanatoriums, with physicians and consultant nurses to correlate them properly and to bring them into harmony with each other in one composite whole.
FOR LAYING DOWN STANDARDS. this phase of the question for the moment, let us Leaving attempt to fix a basis for international standards for public health and welfare work. We must first determine EFFORT MUST BE COORDINATED. our essentials, their relative value, and, on the basis of the Our second essential, then, which may be described as budget available, where the greatest returns from expenditure will be gained ; secondly, we must establish our build- coordinated effort, depends upon the great principle in tubering stoue, our working unit ; finally, we must correlate culosis work which Sir Robert Philip has given to the world these units into a composite whole. and which stands next in relative value to the implements Tuberculosis, as a problem, has taken a prominent place which we have already described. in the formulation of our programme of health. If we had For example, in the fight against tuberculosis we might a specific cure for this malady, much that is now roughlv estimate that for every 250,000 of population we necessary in the campaign would pass into history. It is should need, in our poorer districts, 20 visiting nurses, one because we have no specific cure and must rely upon dispensary, with four or more sub-stations, hospital beds organisation and coordinated effort that it holds its equal in number to the mortality rate, five physicians, five consultant nurses, and a sanitary administrative office to important position at the present time. In the past each country has been guilty of putting an handle hospital admissions, open-air schools, statistics, an It would also be the function exaggerated value upon details which, from time to time, educational campaign, &c. have been suggested and advertised as a means of con- of one section of this office to establish and maintain controlling the malady. You all know them-sanatoria, hos- stant cooperation with those organisations dealing with pitals for advanced cases, dispensaries, mountain colonies, related problems, such as child and maternity welfare, farm colonies, and villages. medical examination of school children, infectious and The great weakness in each one of these if over-emphasised venereal diseases. Through its influence, for instance, a is that it represents but one. detail of a big scheme, and housing programme would be made to include suitable prooften is contrary to higher laws influencing the human vision for that portion of the population suffering from family. For example, infection with the tubercle bacillus tuberculosis which must be cared for at home. At least may at no period be taken as a just ground for a type of 5 per cent. of any,housing programme should be so arranged segregation which does not take account of social, educa- as to isolate and care for tuberculous patients in a household. Such factors of limited and very special use as farm and tional, and financial distinctions. Infection with the tubercle bacillus will not make the lion and the lamb lie down together. mountain colonies would be left to the various private groups, It it could do so many of the problems of the world would which would determine their position in the general probe solved. If it could do so we need now only infect gramme. These institutions would be placed in such relation Italian and Jugo-Slav, infect President Wilson and his to the whole problem as to care for suitable cases for a senate, infect the Bolsheviks, the Irish and the labour given district. Naturally their scope is limited, but the unions, in order to settle many difficulties between groups extent of the region each would serve would be determined of the human familv. by the number of available cases. No. 5017.
THE BASIS
-
DR. A. E.
720
BARCLAY :
IDEALS IN RADIOLOGY AND ELECTROLOGY.
THE RELATION OF CENTRAL TO LOCAL GOVERNMENT. We come next to the problem of the relation of these unit! to central government. If I were to suggest to you in Grea! Britain that there was any relation between the loss of th< American Colonies and your low death-rate from tuber culosis, you would probably laugh me out of court. Ye1 as I study the various speeches outlining your colonia: policy which have been made in your Parliament since thaI loss, I see a different trend given to your statesmanship from that period. As I read also the story of Baron Stein’s appreciation of your municipal and county autonomy which be carried back to Germany as the basis of its policy in forming its new empire after the Peace of Tilsit, I think I can see a definite relation between the thought generated by the loss of American territory and all that has since happened to the British Empire. It may be summed up thus : That your statesmen first learned to release power and have been the fathers in the world of local autonomy. This great principle, I believe, must be grasped by all those interested in every phase of the government of the world. Similarly, the release of power by the central authorities to local authorities, thereby enabling them to adjust equipment in health and welfare and educational matters to the task to be done in their respective localities, is the secret of control of most of our health and welfare
problems. The function, then, of central authority is correlate, suggest, stimulate, and subsidise, and
study,
to
so secure
equable and uniform establishment of standards throughout its kingdom. It will not do, however, to stop at your kingdom or our republic. To set up uniform standards throughout the world is the great privilege and duty of Great Britain, These standards have a America, France, and Italy. special significance for you in your colonies and also for us in America, because we have opened our doors to all the nations under heaven. Had we taken steps to secure uniform methods of health and welfare education and cooperation 50 years ago, we should not now be dealing with the serious problem of foreign groups segregated within the borders of nearly all of our industrial communities.
Address An [ABRIDGED] ON
IDEALS
IN RADIOLOGY AND ELECTROLOGY.
Presidential Address delivered before the Section of ElectroTherapeutics of the Royal Society of Medicine on Oct. 17th, 1919,
BY
ALFRED
HON. MEDICAL
E. BARCLAY,
M.D. CAMB.,
OFFICER, RADIOLOGY AND ELECTRICAL DEPARTMENTS, ROYAL INFIRMARY, MANCHESTER.
LADIES AND GENTLEMEN,—It is a time-honoured custom that the incoming President should address vou on some subject of his choice, and it is with much diffidence that I undertake the task, for I feel very deeply the honour you have done me and the grave responsibilities that are implied. The war has brought into prominence the wide fields that are open for the uses of electricity and other physical forces in medicine, particularly of X rays, with the result that many men are prospecting with a view to taking up the work represented by this section. For instance, in my own city five men are now established in X ray work where formerly there were but two, and I understand that this is more or less the same in all the large towns. I thought, therefore, that it might be of value if I addressed myself particularly to those men who, knowing only the military side of our arts, should know what the future holds if they are to become successful practitioners.
THE NECESSITY FOR TECHNICAL KNOWLEDGE. Whatever view we take of the future possibilities of our branch the present is with us, and one need hardly point out how vast are our opportunities-opening out in so many directions that no one worker can be a master of them all; what a change from 20 years ago, when in a few weeks a man could make himself as competent on the medical side of the subject as was possible. To-day it is a different story, and SUMMARY. to take his place a man must be prepared to master a of subjects such as are necessary in no other branch. chief a are careful of diversity then, first, My suggestions, analysis each region ; second, the establishment of a building unit Of course, it is essential that a man taking up this line of of public health nurse and her territory ; third, the correla- work should know his physics and electricity and all the tion of these on the basis of the Edinburgh principle, with technical work in radiography, radiotherapy, electro-therapy, the added superstructure of other equipment as budget &c., which are carried out for him by lay assistants. He will and necessity permit, but always on the basis of adapta- have to be responsible for the work of his department, and no tion to the region to be handled. To push these standards man is fit to do this who does not know the general principles throughout the world will require constant modifications and the detail of every job that is carried out for him by his based upon a knowledge of language and of the origin and assistants. This argues that he should also know the construction of his apparatus and the theory on which it is conformer condition of the people to be cared for. As a step toward obtaining such knowledge, we have been structed, for it is for him to say what is, and what is not, i able to
international possible
in a small wav a number of in Public Health Nursing. In this we hope the British Empire will join us, so that we may have travelling back and forth between the peoples of the world who differ in language and custom those agents of public health and welfare who mean most in the education of a populace-by teaching them how to carry out the suggestions for their betterment made by physician or other officer. I I have purposely not gone into the other fields associated with tuberculosis, because I believe with a proper building unit once established the correlation and addition of the superstructure is comparatively easy. It should not be difficult, even for an international plan, which on its completion will make it as safe to live in one part of the world as in another, for then in each region the equipment will fit the task, and the task will be outlined according to the first-hand facts and data furnished by each public health nurse for her special district.
begin
scholarships
.
THE
first
meeting
of
the
Lancashire
and
Westmorland Tuberculosis Society will be held on Thursday next, Oct. 30th, at 3 P.M., in the Houldsworth Hall, Deansgate, Manchester, when Dr. G. Lissant Cox, central tuberculosis officer to the Lancashire County Council, will deliver the presidential address. The attendance of medical men interested in tuberculosis is invited.
with the apparatus at his disposal. In short, he must be the master and must be able to talk to his
and any other assistant, and And these things faults in their technique. are outside and introductory to the science and art of medicine, of diagnosis and healing by physical means. The man who takes up this branch must be prepared to master these subjects if he is to approach his specialty from a scientific point of view. The man who by turning on a switch produces such and such a result is as empiric a physician as those of a hundred years ago who loaded a bottle with many different drugs in the hope that some one of the constituents would be of value. He did not know how or why he obtained his result, but at that time the knowledge was not available. To-day the man who fails to know the A B 0 of the science in which he deals is nothing less than a quack, and presumably a lazy one, .for the knowledge is ready to I admit that, at the hand to any man who cares to learn. moment, the knowledge is scattered and has to be sought out, but the establishment of the Diploma at Cambridge, with its very sound syllabus, ensures courses of study where all may obtain the requisite training.
radiographer, photographer, correct
SPECIALISED TEACHING.
importance of specialised teaching for our patent, especially to those of us who had
The is
way into it, the equipment
ur
own
for,
or
branch
to find not knowing what we were in of medical knowledge necessary;