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Influence of migration on death rates
354
PUBLIC t4EALTH.
therefore i m p o r t a n t t h a t the R e g i s t r a r - G e n e r a l be notified without delay' if it is p r o p o s e d to take a d v a n t a g e of this offer. F o r m s for the purpose, t o g e t h e r xxith an e x p l a n a t o r y m e m o r a n d u m have been sent to the Clerks of Local Authorities, but as these officials do not ahvays p a s s on the information to the medical officer of health, we advise tim l a t t e r to t a k e steps to ensure that the o r d e r form is sent in at once. It is a little u n f o r t u n a t e that the Ministry sends out this request as well as a n u m b e r of other Circulars and M e m o r a n d a at this p a r t i c u l a r season, when most authorilies are in recess, and officials a w a y on holiday. It is a m i s t a k e from a business point of view to issue such documents in the month of A u g u s t . INFLUENCE
OF MIGRATION RATES.
ON
DEATH
In his presidential a d d r e s s to the Epidemiological Section of the R o y a l Society of Medicine, in 1912, Sir \ ¥ i l l i a m H a m e r discussed the effect which m i g r a t i o n had on phthisis death rates, and s u g g e s t e d that internal m i g r a t i o n w a s an imp o r t a n t factor in c o n t r a s t i n g rates of mortality. The question has been considered by the Medical Research Cotlncil, and they found t h a t k n o w l e d g e of the precise effects of m i g r a t i o n and even of the g e n e r a l conditions of life in rural districts upon m o r t a l i t y was very scanty. T o u n d e r t a k e a t h o r o u g h study of the question would involve an enquiry e x t e n d i n g over the whole country, which was more than they could u n d e r t a k e . They resolved, however, to institute a small-scale enquiry in a sample area, with the object of determ i n i n g what kind o£ information could actually be obtained, and w h e t h e r the results of a first e s s a y were sufficiently v a l u a b l e to iustify a complete investigation. The C o u n t y of E s s e x was chosen for this purpose, and a r e p o r t prepared by Mr. A. B. Hill, B.Sc., has recently been issued. It has involved a g r e a t deal of w o r k which has been done very t h o r o u g h l y , but, unfortunately, o w i n g to the s p a r s i t y of d a t a , the result reached is indecisive, and it does not seem p r o b a b l e that any similar i n v e s t i g a t i o n would r e p a y the effort. A l t h o u g h the enquiry has been d i s a p p o i n t i n g as r e g a r d s its original objective, as so often happens in research work, other results have e m e r g e d which are more r e w a r d i n g . The historical development of m i g r a t i o n e x t e n d i n g over a period of 120 years, and the inferences deduced from the figures are w o r t h y of attention, and the dietetic s t u d y increases a p p r e c i a b l y o u r k n o w l e d g e of the
SEPTEMBER,
p r e s e n t nutritional level of the p o p u l a t i o n of our rural areas. The enquiry confirms, a l t h o u g h it does not definitely prove, the view that m i g r a n t s from the County r e p r e s e n t the healthier m e m b e r s of the rural commtlnity, a n d that they retain their adv a n t a g e in an urban environment in c o m p a r i s o n with other urban residents. ~ Conversely the tendency is for the w e a k e r (mentally if not physically) to remain behind. This n a t u r a l l y m i g h t lead to a h i g h e r d e a t h - r a t e , and while the rates are lower in E s s e x R u r a l D i s t r i c t s than for E n g land and \Vales at all a g e periods 5 to 65, yet in the g r o u p s 15-20-25 the rates more closely a p p r o x i m a t e to the rates f o r the whole country, and for females a r e h i g h e r than for London, which evidently benefits by the influx of healthy persons at that age. Very few m i g r a n t s a p p e a r to return home on account of loss of health. W h e t h e r the theory that a less v i g o r o u s population is left at home be true or not, recognition must be given to the possibility of other factors of rural life being such as to place the " h o m e k e e p e r s " at a d i s a d v a n t a g e when c o m p a r e d with their b r o t h e r s and sisters in the towns. The g e n e r a l evidence w a s that the state of the housing in the rural districts of Essex is to be deplored ; that m a n y of the c o t t a g e s are small and oldfashioned, with insufficient accommodation, especially for sleeping p u r p o s e s ; that many of them are cold and d a m p and defective in ventilat i o n ; and t h a t in m a n y of them the s a n i t a r y conveniences and d r a i n a g e are both primitive and objectionable from every point of view. F o r their w a t e r supply the p o p u l a t i o n is too often d e p e n d a n t upon rain w a t e r , ponds and shallow wells. As a set-off, the g r e a t e r p a r t of the rural p o p u l a t i o n is l e a d i n g an open-air life, with pure air and sunlight. Enquiries were made as to f o o d ; in m a n y cases the diet a p p e a r e d to be low, but it was difficult to obtain reliable figures, or to e s t i m a t e to what e x t e n t b o u g h t food was s u p p l e m e n t e d by g a r d e n produce c a r r y i n g with it a supply of vitamins. G a u g e d by observation of the children, very few cases showed signs of m a l - n u t r i t i o n or lack of g r o w t h ; in fact, when c o m p a r e d with e l e m e n t a r y school children of coal-miners in the N o r t h or Midlands, the children of E s s e x agricul~'Enquiry was made as to the birth-place of each person, including Jews, attending the tuberculosis dispensaries in the Borough of Stepney, in order to supplement the information as to whether the migrant had failed in that direction. It would have been better had the enquiry been made ;n other London Boroughs, such as Westminster, St. Marylebone, or Kensington, which have a larger proportion of British born migrants than has Stepney.
PUBLIC HEALTH.
1925.
tural Iabourers show to a d v a n t a g e both as r e g a r d s h e i g h t and weight. The enquiry seems to indicate t h a t the d e a t h - r a t e of the districts in which the m i g r a n t t a k e s up residence benefits, while the rural d e a t h - r a t e suffers. Mr. Hill a p p e a r s to think t h a t a g r e a t e r share in the production of an excessive d e a t h - r a t e is to be a t t r i b u t e d to a population, w e a k e n e d by selection, s u c c u m b i n g to disease which the g e n e r a l conditions of their life did not assist t h e m to overcome.
ARTIFICIAL
SUNLIGHT
CLINICS.
The r e m a r k a b l y rapid g r o w t h d u r i n g the p a s t four y e a r s of the cult of t r e a t m e n t by sunlight in this country~ and artificial s u b s t i t u t e s for sunlight, is a p h e n o m e n o n which has not p e r h a p s been fully r e c o g n i s e d ; t h o u g h it is sufficiently s t r i k i n g when c o n t r a s t e d with the slow, s t e a d y g r o w t h usually experienced in the d e v e l o p m e n t of a particular a s p e c t of Public H e a l t h in E n g l a n d and \Vales. A p a r t from the increased facilities for t r e a t m e n t by the s u n ' s r a y s at v a r i o u s institutions d e a l i n g with the y o u n g child, the crippled child, and the tuberculous patient, there has been a l a r g e extension in the provision of clinics~ either municipal or at v o l u n t a r y hospitals, for t r e a t m e n t by artificial sunlight. The city of K i n g s t o n - u p o n Hull h a s been a pioneer in this respect, and it is of i n t e r e s t to note the r e p o r t p r e s e n t e d by the Medical Officer of H e a l t h , Dr. Allen Daley, to his c o m m i t t e e on the p r o g r e s s of the work. T h e first municipal clinic in this country for the t r e a t m e n t of rachitic children by artificial sunlight was e s t a b l i s h e d in Hull, t h r o u g h the g e n e r o s i t y of a m e m b e r of the City Council, Mr. P e r c y Hall. A t u n g s t e n arc l a m p was provided, and p a t i e n t s were under t r e a t m e n t in April, 1914. The t r e a t m e n t is at p r e s e n t limited to children seen under the m a t e r n i t y and child welfare s c h e m e ; but the hope is clearly implied in the report t h a t such t r e a t m e n t will be e x t e n d e d to meet the needs of tuberculous patients. T h e course of t r e a t m e n t lasts a b o u t six weeks, but in m a n y cases a repetition of the course is necessary. T h e p r o o f - - i f any were n e e d e d - - t h a t the clinic is p o p u l a r is shown by the fact t h a t over one-third of the children a t t e n d i n g c a m e from p o r t i o n s of the town n e c e s s i t a t i n g a c h a n g e from one t r a m to a n o t h e r before r e a c h i n g the clinic. A t t a c h e d to Dr. D a l e y ' s r e p o r t is one from Dr. K a t h e r i n e G a m g e e , the medical officer responsible for the conduct of the clinic. It is clear t h a t the p o p u l a r i t y of the clinic is steadily and rapidly
355
increasing, and that the p r o m i n e n t fe~,ture in the t r e a t m e n t is the r e m a r k a b l e increase in liveliness of the children, often first noticed by the mothers, who further c o m m e n t on the child b e i n g able to sleep better, and being far less trouble at home. The extension of clinics of the t y p e referred to here must inevitably, and before very long, b r i n g increased attention to b e a r on m o r e general methods of p r e v e n t i n g the loss of n a t u r a l sunshine now so g e n e r a l l y experienced in the s m o k y atmosphere of all the l a r g e r and some even of our smaller towns. Hull i t s e l f - - t o use as an illustration this city which is so well to the front in the m a t t e r of artificial light t r e a t m e n t - - w o u I d have far fewer children to send to such a clinic for t r e a t m e a t by synthetic sunshine, were it able to eliminate the smoke which so m a t e r i a l l y diminishes the effectiveness of its n a t u r a l sunshine.
PURE MILK.
It is with sincere g r a t i t u d e to Dr. W i l l i a m S a v a g e t h a t we r e c o m m e n d his p a m p h l e t on the Mill< Supply and its I m p r o v e m e n t * to all practitioners and students of Public H e a i t h . N o b o d y professes to u n d e r s t a n d fully the hopeless muddle which surrounds the milk supply in E n g l a n d , but Dr. S a v a g e is certainly the clearest exponent of the subject, and, unlike most authorities on milk, he leaves his readers, after they have read his pamphlet, less confused than they were before. The happiest country is t h a t which has no history. May we p r e s u m e th~it the happiest t r a d e is that which has no l e g i s l a t i o n ? If so, we can u n d e r s t a n d the sorry plight of the milk trade, for nothing has been l e g i s l a t e d for so much or legislated for so ill. Act after Act, O r d e r after Order, modifying, altering, r e v e r s i n g (but seldom repealing) those which have g o n e before, yet all a g r e e i n g in a d m i t t i n g s a f e g u a r d s which render them useless and e l a b o r a t e processes, which render them unworkable, have been thrust upon us, so t h a t most of us d o n ' t , w o n ' t , or c a n ' t c a r r y them out and there is very little gained by those who do. Less milk is d r u n k in E n g l a n d than in any o t h e r civilized country. W h y ? Because no one can recommend milk as a food w i t h o u t equivocations and c a u t i o n s - - a n d the g e n e r a l m a s s of mankind is bored by e x p l a n a t i o n s and w o n ' t be + " The Milk £upply and its Improvement," by William G. Savage, B.Sc., M.B.Lond., reprinted from The Lancet.
PUBLIC t4EALTH.
therefore i m p o r t a n t t h a t the R e g i s t r a r - G e n e r a l be notified without delay' if it is p r o p o s e d to take a d v a n t a g e of this offer. F o r m s for the purpose, t o g e t h e r xxith an e x p l a n a t o r y m e m o r a n d u m have been sent to the Clerks of Local Authorities, but as these officials do not ahvays p a s s on the information to the medical officer of health, we advise tim l a t t e r to t a k e steps to ensure that the o r d e r form is sent in at once. It is a little u n f o r t u n a t e that the Ministry sends out this request as well as a n u m b e r of other Circulars and M e m o r a n d a at this p a r t i c u l a r season, when most authorilies are in recess, and officials a w a y on holiday. It is a m i s t a k e from a business point of view to issue such documents in the month of A u g u s t . INFLUENCE
OF MIGRATION RATES.
ON
DEATH
In his presidential a d d r e s s to the Epidemiological Section of the R o y a l Society of Medicine, in 1912, Sir \ ¥ i l l i a m H a m e r discussed the effect which m i g r a t i o n had on phthisis death rates, and s u g g e s t e d that internal m i g r a t i o n w a s an imp o r t a n t factor in c o n t r a s t i n g rates of mortality. The question has been considered by the Medical Research Cotlncil, and they found t h a t k n o w l e d g e of the precise effects of m i g r a t i o n and even of the g e n e r a l conditions of life in rural districts upon m o r t a l i t y was very scanty. T o u n d e r t a k e a t h o r o u g h study of the question would involve an enquiry e x t e n d i n g over the whole country, which was more than they could u n d e r t a k e . They resolved, however, to institute a small-scale enquiry in a sample area, with the object of determ i n i n g what kind o£ information could actually be obtained, and w h e t h e r the results of a first e s s a y were sufficiently v a l u a b l e to iustify a complete investigation. The C o u n t y of E s s e x was chosen for this purpose, and a r e p o r t prepared by Mr. A. B. Hill, B.Sc., has recently been issued. It has involved a g r e a t deal of w o r k which has been done very t h o r o u g h l y , but, unfortunately, o w i n g to the s p a r s i t y of d a t a , the result reached is indecisive, and it does not seem p r o b a b l e that any similar i n v e s t i g a t i o n would r e p a y the effort. A l t h o u g h the enquiry has been d i s a p p o i n t i n g as r e g a r d s its original objective, as so often happens in research work, other results have e m e r g e d which are more r e w a r d i n g . The historical development of m i g r a t i o n e x t e n d i n g over a period of 120 years, and the inferences deduced from the figures are w o r t h y of attention, and the dietetic s t u d y increases a p p r e c i a b l y o u r k n o w l e d g e of the
SEPTEMBER,
p r e s e n t nutritional level of the p o p u l a t i o n of our rural areas. The enquiry confirms, a l t h o u g h it does not definitely prove, the view that m i g r a n t s from the County r e p r e s e n t the healthier m e m b e r s of the rural commtlnity, a n d that they retain their adv a n t a g e in an urban environment in c o m p a r i s o n with other urban residents. ~ Conversely the tendency is for the w e a k e r (mentally if not physically) to remain behind. This n a t u r a l l y m i g h t lead to a h i g h e r d e a t h - r a t e , and while the rates are lower in E s s e x R u r a l D i s t r i c t s than for E n g land and \Vales at all a g e periods 5 to 65, yet in the g r o u p s 15-20-25 the rates more closely a p p r o x i m a t e to the rates f o r the whole country, and for females a r e h i g h e r than for London, which evidently benefits by the influx of healthy persons at that age. Very few m i g r a n t s a p p e a r to return home on account of loss of health. W h e t h e r the theory that a less v i g o r o u s population is left at home be true or not, recognition must be given to the possibility of other factors of rural life being such as to place the " h o m e k e e p e r s " at a d i s a d v a n t a g e when c o m p a r e d with their b r o t h e r s and sisters in the towns. The g e n e r a l evidence w a s that the state of the housing in the rural districts of Essex is to be deplored ; that m a n y of the c o t t a g e s are small and oldfashioned, with insufficient accommodation, especially for sleeping p u r p o s e s ; that many of them are cold and d a m p and defective in ventilat i o n ; and t h a t in m a n y of them the s a n i t a r y conveniences and d r a i n a g e are both primitive and objectionable from every point of view. F o r their w a t e r supply the p o p u l a t i o n is too often d e p e n d a n t upon rain w a t e r , ponds and shallow wells. As a set-off, the g r e a t e r p a r t of the rural p o p u l a t i o n is l e a d i n g an open-air life, with pure air and sunlight. Enquiries were made as to f o o d ; in m a n y cases the diet a p p e a r e d to be low, but it was difficult to obtain reliable figures, or to e s t i m a t e to what e x t e n t b o u g h t food was s u p p l e m e n t e d by g a r d e n produce c a r r y i n g with it a supply of vitamins. G a u g e d by observation of the children, very few cases showed signs of m a l - n u t r i t i o n or lack of g r o w t h ; in fact, when c o m p a r e d with e l e m e n t a r y school children of coal-miners in the N o r t h or Midlands, the children of E s s e x agricul~'Enquiry was made as to the birth-place of each person, including Jews, attending the tuberculosis dispensaries in the Borough of Stepney, in order to supplement the information as to whether the migrant had failed in that direction. It would have been better had the enquiry been made ;n other London Boroughs, such as Westminster, St. Marylebone, or Kensington, which have a larger proportion of British born migrants than has Stepney.
PUBLIC HEALTH.
1925.
tural Iabourers show to a d v a n t a g e both as r e g a r d s h e i g h t and weight. The enquiry seems to indicate t h a t the d e a t h - r a t e of the districts in which the m i g r a n t t a k e s up residence benefits, while the rural d e a t h - r a t e suffers. Mr. Hill a p p e a r s to think t h a t a g r e a t e r share in the production of an excessive d e a t h - r a t e is to be a t t r i b u t e d to a population, w e a k e n e d by selection, s u c c u m b i n g to disease which the g e n e r a l conditions of their life did not assist t h e m to overcome.
ARTIFICIAL
SUNLIGHT
CLINICS.
The r e m a r k a b l y rapid g r o w t h d u r i n g the p a s t four y e a r s of the cult of t r e a t m e n t by sunlight in this country~ and artificial s u b s t i t u t e s for sunlight, is a p h e n o m e n o n which has not p e r h a p s been fully r e c o g n i s e d ; t h o u g h it is sufficiently s t r i k i n g when c o n t r a s t e d with the slow, s t e a d y g r o w t h usually experienced in the d e v e l o p m e n t of a particular a s p e c t of Public H e a l t h in E n g l a n d and \Vales. A p a r t from the increased facilities for t r e a t m e n t by the s u n ' s r a y s at v a r i o u s institutions d e a l i n g with the y o u n g child, the crippled child, and the tuberculous patient, there has been a l a r g e extension in the provision of clinics~ either municipal or at v o l u n t a r y hospitals, for t r e a t m e n t by artificial sunlight. The city of K i n g s t o n - u p o n Hull h a s been a pioneer in this respect, and it is of i n t e r e s t to note the r e p o r t p r e s e n t e d by the Medical Officer of H e a l t h , Dr. Allen Daley, to his c o m m i t t e e on the p r o g r e s s of the work. T h e first municipal clinic in this country for the t r e a t m e n t of rachitic children by artificial sunlight was e s t a b l i s h e d in Hull, t h r o u g h the g e n e r o s i t y of a m e m b e r of the City Council, Mr. P e r c y Hall. A t u n g s t e n arc l a m p was provided, and p a t i e n t s were under t r e a t m e n t in April, 1914. The t r e a t m e n t is at p r e s e n t limited to children seen under the m a t e r n i t y and child welfare s c h e m e ; but the hope is clearly implied in the report t h a t such t r e a t m e n t will be e x t e n d e d to meet the needs of tuberculous patients. T h e course of t r e a t m e n t lasts a b o u t six weeks, but in m a n y cases a repetition of the course is necessary. T h e p r o o f - - i f any were n e e d e d - - t h a t the clinic is p o p u l a r is shown by the fact t h a t over one-third of the children a t t e n d i n g c a m e from p o r t i o n s of the town n e c e s s i t a t i n g a c h a n g e from one t r a m to a n o t h e r before r e a c h i n g the clinic. A t t a c h e d to Dr. D a l e y ' s r e p o r t is one from Dr. K a t h e r i n e G a m g e e , the medical officer responsible for the conduct of the clinic. It is clear t h a t the p o p u l a r i t y of the clinic is steadily and rapidly
355
increasing, and that the p r o m i n e n t fe~,ture in the t r e a t m e n t is the r e m a r k a b l e increase in liveliness of the children, often first noticed by the mothers, who further c o m m e n t on the child b e i n g able to sleep better, and being far less trouble at home. The extension of clinics of the t y p e referred to here must inevitably, and before very long, b r i n g increased attention to b e a r on m o r e general methods of p r e v e n t i n g the loss of n a t u r a l sunshine now so g e n e r a l l y experienced in the s m o k y atmosphere of all the l a r g e r and some even of our smaller towns. Hull i t s e l f - - t o use as an illustration this city which is so well to the front in the m a t t e r of artificial light t r e a t m e n t - - w o u I d have far fewer children to send to such a clinic for t r e a t m e a t by synthetic sunshine, were it able to eliminate the smoke which so m a t e r i a l l y diminishes the effectiveness of its n a t u r a l sunshine.
PURE MILK.
It is with sincere g r a t i t u d e to Dr. W i l l i a m S a v a g e t h a t we r e c o m m e n d his p a m p h l e t on the Mill< Supply and its I m p r o v e m e n t * to all practitioners and students of Public H e a i t h . N o b o d y professes to u n d e r s t a n d fully the hopeless muddle which surrounds the milk supply in E n g l a n d , but Dr. S a v a g e is certainly the clearest exponent of the subject, and, unlike most authorities on milk, he leaves his readers, after they have read his pamphlet, less confused than they were before. The happiest country is t h a t which has no history. May we p r e s u m e th~it the happiest t r a d e is that which has no l e g i s l a t i o n ? If so, we can u n d e r s t a n d the sorry plight of the milk trade, for nothing has been l e g i s l a t e d for so much or legislated for so ill. Act after Act, O r d e r after Order, modifying, altering, r e v e r s i n g (but seldom repealing) those which have g o n e before, yet all a g r e e i n g in a d m i t t i n g s a f e g u a r d s which render them useless and e l a b o r a t e processes, which render them unworkable, have been thrust upon us, so t h a t most of us d o n ' t , w o n ' t , or c a n ' t c a r r y them out and there is very little gained by those who do. Less milk is d r u n k in E n g l a n d than in any o t h e r civilized country. W h y ? Because no one can recommend milk as a food w i t h o u t equivocations and c a u t i o n s - - a n d the g e n e r a l m a s s of mankind is bored by e x p l a n a t i o n s and w o n ' t be + " The Milk £upply and its Improvement," by William G. Savage, B.Sc., M.B.Lond., reprinted from The Lancet.