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The public health services in the war
1942 THE
PUBLIC HEALTH PUBLIC
HEALTH SERVICES THE WAR *
IN
By SIR ALEXANDER MACGREGOR, O.B.E., M.D., LL.D., F.R.F.P.S.GLAS., J.P.,
Medical O~fcer of Health, Glasgow I am deeply sensible of the high honour which the Society of Medical Officers of Health has conferred on me by appointing me its President. In assuming this high office, I must take this, the first, opportunity of thanking my predecessor, Dr. F. T. H. Wood, for undertaking a second year of office, because I know that he carried on during a very difficult period. I am sure the members of the Society are most grateful to him for this service, as well as for the unrivalled knowledge of public health affairs which he has long placed, and will, I hope, continue to place at their disposal. I am the third holder of this office to hail from Scotland. Dr. A. K. Chalmers held it in 1913, when I was a junior member of his staff. Since his day there has been almost a revolution in public health thought and practice in both our countries, although there are some differences in our respective powers and in the manner of conducting our affairs. In England and Wales you have your great Public Health Act of 1936, while we in Scotland are still waiting for a similar Act, delayed owing to the war. Perhaps we will improve upon it, on the principle of the game of leap-frog. Now that the whole country is on the eve of further advances in public health, it is gratifying to know that the chiefs of our respective services, Sir Wilson Jameson and Dr. Andrew Davidson, have arranged to co-operate with each other in the consideration of our common problems and to encourage a better two-way traffic of knowledge and ideas than has obtained in the past. The public health service occupies a highly responsible place in the war effort; it is passing through a period of great activity and is doing its best to meet all the demands made upon it. New functions have been acquired, and many difficult problems have arisen involving changes in method and outlook, so that the service has largely outgrown its former character and scope. At the same time it is gaining a wealth of new experience which will be of the greatest value in the future; indeed, it may be said that the positive health policy which was slowly evolving in pre-war times has begun to assume a much clearer outline. The functions of public health departments in these days group themselves under three main heads. First, there are the new special emergency services working in close association with or grafted on to public health administration. Secondly, there are the normal health activities adapted and expanded to meet conditions arising out of the war the pre-war problems of health in a new setting. Thirdly, post-war problems are pressing for attention, on which our experience of what is happen=. • Presidential Address to the 8ociety of Medical Officers of Health, November 21st, 1941.
ing now will have an important bearing, because it seems clear that the foundations of future advances in the sphere of public health and social medicine are even now being laid. No one regrets more than I do the curtailment of our opportunities for discussion of our joint affairs, as a result of which I am somewhat out of touch with public health developments in other parts of the country. I shall therefore ask ),our indulgence if I draw largely on local experience in the following remarks on one or two topics which I have chosen from the three heads I have mentioned. A i r R a i d Preoautions Medical officers of health and their staffs are deeply engrossed in the immediate concerns of the war. For the past two years local authorities have carried out big and exacting Government programmes for the health and safety of those on the home front. Many new and unaccustomed duties, both executive and advisory, have been undertaken by public health departments. Much of this work is of a purely emergency kind, such as the organisation of the firstaid and casualty service and co-operation with the Government in many other activities incidental to the war effort--for instance, the emergency hospital scheme, recruitment of nurses, the evacuation arrangements (which have thrown special responsibilities on receiving areas), health and sanitation in shelters and rest centres, salvage of foodstuffs, and sanitary measures following air raids. A quite extraordinary amount of time and energy has been expended on these duties by public health officers throughout the country, not without many anxious and difficult moments. I have specially mentioned these aspects of civil defence, because I am sure the Society will wish to pay a warm tribute to all branches of our public health and sanitary staffs for the effective manner in which they have served the community, as well as for the hard work cheerfully undertaken in the conduct of these special war services in addition to their ordinary duties, very often in defiance of all risks and dangers. It has not been easy for them to preserve a due balance between civil defence requirements and those of public health, but they realise, I am sure, that morale in time of war is much heightened by the confidence which the public reposes in both these aspects of their work. Health visitors in particular, from the closeness of their contact with the homes and daily lives of the people, are assisting in no small degree to sustain the spirit of the nation. It is from them that medical officers of health derive much of their insight into the welfare of families, particularly the condition of the children. The Society will also wish to recognise the indebtedness of the casualty service to medical practitioners throughout the country, who have been eager to take a place in them whenever occasion required. Most of us have had experience of the casualty service in action, and can bear witness to the high courage and resourcefulness under fire shown by the large army of volunteers who have enrolled themselves in this service; their keenness to serve when called upon has been beyond all expectation.
81
PUBLIC HEALTH I sometimes wonder whether a way could be found to attract some at least of these volunteers into social work after the war. Many of them would give as valuable service to the community in peace as they are now giving in time of war.
Health and the War I think it is correct to say that the health of the people has been better than was in fact expected, in spite of the new factors which the war has introduced, such as new dispositions of population, overcrowding, the black-out, hard work, and other influences. It is true that certain wide movements of sickness and mortality have taken place concurrently with the war, though not attributable to it. For instance, a wave of diphtheria has been passing over various parts of the country and its force is not yet spent; an epidemic of whooping-cough of quite unusual magnitude occurred in 1940-41 with severe consequences to infants and young children; outbreaks of paratyphoid fever have become more frequent. During the early months of 1940, and again in 1941, prolonged spells of cold weather increased the incidence and mortality due to pneumonia and bronchitis among the elderly and the very young. Professor R. M. F. Picken (1941), in his striking exposition of the effect of a hard winter in London, relates the kind of experience to which we in Scotland are more accustomed on account of the greater vagaries of our northern climate. It would, I think, be in accord with public health experience of the variations of disease from year to year to conclude that these major trends of sickness had little, if anything, to do with conditions arising out of the war. On the other hand, present conditions may be regarded as contributing to an increased incidence of tuberculosis, a restless behaviour of cerebrospinal fever, and a " considerable rise in the number of deaths due to premature birth" as recently recorded in Scottish Vital Statistics, which will be referred to later. Tuberculosis of the lungs and, to a much less extent, non-pulmonary tuberculosis have been rising in Glasgow during the past two years, as is also the case elsewhere. On looking closely at the position in Glasgow, we find that notifications of pulmonary tuberculosis during 1940 increased by about 20 per cent. over the 1939 figure, while the death rate rose very much to the same extent. Comparing 1941 with 1940, it is estimated, on the basis of cases notified during the first ten months, that the incidence for this year will be only 8 per cent. in excess of that for 1940, while the death rate will not be greater. Thus the sharp initial rise that took place in 1940 has been followed by a definite slowing down of the rate of increase of pulmonary tuberculosis. This rise relates almost entirely to males between 15 and 45 and to females between 15 and 35 years of age. These are the working ages and the ages when tuberculosis most often declares itself. There are probably one or two reasons for this increase, but the main reason is to be found in the entry of large numbers of young people into employment; the probability is that an infection that would have been resisted in normal times gains the upper hand. Laidlaw and 82
~ANUARY Macfarlane (1941) attribute this rise to a combination of long hours, overtime, strain, and ill-spent leisure. I may next refer to some disorders in which environmental factors act as predisposing causes. Unemployment is generally recognised to be a fertile source of subnormal health or of actual mental or bodily illhealth. Where social conditions are such that work and wages are plentiful, a reduced incidence of those ill-defined mental and physical disorders that are apt to be engendered by an aimless life may confidently be expected. The evidence available supports this view. If to these social advantages be added a high purpose in life, the general effect is such as to afford an explanation of the fact much commented u p o n - namely, the surprisingly small incidence of neuroses in spite of conditions that might have been expected to produce them in considerable volume. Present-dav conditions have, in fact, greatly reduced the prevai'ence of these ailments, especially among the male population. What this experience means is that progress towards social security is progress towards better health.
Food and the War The most outstanding of the health measures that have come into operation are those dealing with the food supply. The Ministry of Food, in spite of great difficulties, has shown the utmost wisdom in its determination to bring within reach of all the staple articles of diet and to make available to those who need it moat the right kind of food--as, for instance, milk and the protective foods for young children, and for nursing and expectant mothers. Canteens for industrial workers are a long-overdue health measure and should become permanent; they have an important bearing on the relation between housing and industry. Whatever view may ultimately be taken of communal feeding, I hope that the industrial canteen and the school meal have come to stay. These and other practical provisions, to which should be added the stimulus that has been given to the spread of knowledge of food values and to the teaching of cookery, constitute a group of measures applied at the very source of national health and well-being. As the work that the Ministry of Food is now doing in these ways, which may be described as anticipatory and preventive, is of such immense value to the community, I fervently hope that when peace returns it will be found possible to retain in being the Ministry or its equivalent as an essential health service, and so make permanent what would be in effect the greatest because the most beneficial of all the health services. Family catering is a responsible business in these days, and it is not easy to apportion a proper share of the available foods to each member of the family. Restrictions due to rationing and price are perhaps most felt in industrial areas, while families with young children have had to make some difficult adjustments. Those of us who are watching closely the effect of food control will have observed a number of changes for the better in food habits. In my experience there is no doubt that the manner in which the
1942 Ministry of Food is handling the food situation is making a deep impression on the attitude of the people to the common articles of diet. The childwelfare service is called upon to advise mothers on the feeding of children and to keep an eye upon household dietaries. In carrying out these duties, the health visitors, who are in a position to report on the food habits of the average householder, have noted the following broad tendencies. The National Milk Scheme has created a definite "milk psychology"; more milk is consumed than ever before, and mothers agree that this is one of the best services that has been rendered to their children. They view with great anxiety the recent cut in supplies, which reduces the amount of non-priority milk available. Porridge has returned to favour in a large way. The nutritious herring, which was for some reason difficult to popularise, is in great demand. A new impetus has been given to the consumption of vegetables and fruit, which appear to have become increasingly popular for their own sake. It is stated that since the last war the country had increased its consumption of fruit by 90 per cent., of vegetables by 60 per cent., and of milk by 50 per cent. Thus, it may be said that the exigencies of war and the food policy of the Government have accelerated the progress that had been recorded in the consumption of essential foodstuffs. These are solid advances in the national dietary; they represent definite progress towards a more wholesome food r~gime, a progress that we may hope will never be checked or reversed, because we know what the improved feeding of the pre-war years has already done for the health of the people. We now see going on a great experiment in social medicine, conducted though it is in the hard school of war, leading to the formation of more wholesome feeding habits and to a knowledge of food values aided by persistent propaganda, combined with a national policy which is making the most essential of the foodstuffs available to all in the homes of the people, in canteens, and in schools.
Henlth in the Schools Observations on the physical condition of school children are reassuring. Education was at first completely dislocated by the big exodus of children from the cities to the country. When a large percentage of the evacuees subsequently returned school attendance was gradually restored, but under a greatly modified r6gime. In these circumstances, while general supervision of school children was maintained it was not possible to continue the routine measurements of height and weight--at any rate to an extent that would make them strictly comparable with those of former years. I may, however, mention certain measurements taken in the Glasgow schools between September 1940 and April 1941 of some 6-7,000 boys and the same number of girls at the ages of 5 and 13. All the measurements were an improvement upon those for 1939, particularly in the case of school entrants. Although evacuation and interference with school attendance disturbed the representative nature
PUBLIC HEALTH of these groups, the results may be accepted as implying that school children have lost none of the improved physical condition that has been so marked a feature in recent years. One or two influences on school children caused by the emergency seem well worth mentioning. First, it was found that absenteeism from school meant absenteeism also from the clinics, so that defects that would normally have been noticed and rectified went undetected and untreated even though a follow-up system was set up. This experience showed ver,¢ clearly how much the school medical service is dependent for its success on the care and vigilance of the teachers. Secondly, factors that conduce to misdirected energy and juvenile delinquency have been intensified, leading to an increased need for child guidance among other measures advocated to counteract this tendency. Thirdly, it was discovered that more children had verminous infestation of the head than was previously suspected, and that with the aid of a comb and magnifying glass the presence of nits or lice or both could be detected in at least 40 per cent. of school children; in some schools the figure was still higher. This is much the same figure ~s Kenneth Mellanby (1941) found in his special inquiry in England. Vermin on body clothing--a worse form of infestation that used to be very common--is now relatively infrequent, but the head louse has obtained a fresh lease of life protected by the new feminine styles of hair, among which it can live and multiply as an unnoticed or accepted tenant. When this information was passed on to parents it was received with varied emotions--astonishment, disbelief, resentment, indifference. This discovery is a forcible reminder that standards of cleanliness are still too low. Conditions such as verminous infestation and scabies need not and should not spread to the extent they do. This is surely a matter for parents themselves to deal with, and it is quite wrong that responsibility for low standards of cleanliness should be laid on public health departments. This recent experience strengthens the view that health and welfare in schools could be further improved by making them a more clearly defined branch of education. In this opinion I may say that the Director of Education in Glasgow, Mr. R. M. Allardyce, and myself are agreed, while the teachers, whose interest has now been fully awakened by social events and by the turmoil of evacuation, are eager to co-operate and to help forward a policy in which they would be active partners not only in health education but also in the care and welfare of their charges. Towards the close of last year the Education Committee in Glasgow decided to try out an important experiment in six of the bigger primary schools by arranging for the senior woman assistant to give her whole time to personal hygiene, with the help of a lay assistant, the duties to include the welfare work of the schools (i.e., clothing, milk, meals, and cleanliness). This experiment has been an unqualified success. It was natural that at the outset of the scheme cleanliness and freedom from vermin should be the first objective, and these teachers, along with their lay helpers, devoted their attention specially
83
PUBLIC HEALTH to this problem, interviewing parents, inspecting the children, and enlisting their interest in correct habits and behaviour as only teachers can. Infested heads and dirty clothing were dealt with on the spot. As a result of their work during the first three or four months they were able to report an outstanding improvement in the percentage of children who could be classed as "clean and well cared for," the term " c l e a n " meaning complete freedom from any sign of nits or vermin in the head. In the case of boys, the percentage so classified rose from 55 per cent. to about 80 per cent.; in the case of girls, from 30 per cent. to 65 per cent., a very high standard being adopted. More particularly the incidence of infestation fell as follows: (a) children with verminous heads, from 5 to 2 per cent. in the case of boys, and from 14 to 4 per cent. in the case of girls; (b) children with nits only in the hair, from 30 to 12 per cent. in the case of boys, and from 50 to 25 per cent. in the case of girls.. It is not, of course, intended that this should be the sole function of those taking part in the scheme. Besides giving practical instruction in personal hygiene and assisting actively in its practice, they keep a watchful eye on the general health of the scholars, co-operating with the other teachers and with the school doctors and nurses. They are also responsible for selecting and recommending pupils for free meals and for free boots and clothing. Apart from this experiment, a special short trial course of piactical instruction with demonstrations was given to some sixty senior women assistants, so as to acquaint them with the kind of health problems they would be likely to encounter in their work. A further instance of this teacher-pupil relationship is seen in the problem of child guidance. Much consideration is being given throughout the country to the best methods of administering and staffing this valuable and growing service. In some quarters it is considered that the supervision of children should be carried out at a clinic staffed by medical specialists and specially trained social workers. As this is a controversial topic it may be of interest if I mention the basis of the scheme as operated in Glasgow. Child guidance is regarded as an integral part of the education system, the key workers in it being trained teacher psychologists who also carry out the domiciliary inquiries and home supervision. The medical and psychiatric side is under thec0ntrol of the Education Health Service, and at each stage of development there is close co-operation and consultation between the education and the health administrations. The aim is to preserve an unbroken link between the school, the child-guidance clinic, and the residential home for more difficult cases, treatment being in the hands of teacher psychologists in co-operation with psychiatrists. This scheme was inaugurated after careful consideration, and it was regarded as fundamental that the staff conducting it should possess a background of teachin~ experience as well as a training in psychology. O f course, everything depends on careful choice of personnel. From the results that are being obtained I am fully convinced b a t these arrangements are soundly conceived and are working admirably in practice. 84
~ANUARY I have dwelt upon these developments because we in Glasgow are quite convinced that we are proceeding here on the right lines. Health education, physical fitness, welfare, care of health, child guidance--the more these measures evolve from within the schools themselves the more successful will be the results. I notice that the Board of Education and the Scottish Education Department are engaged in the preparation of plans to renrganise education after the war. Among these plans I should like to see a definite organisation for the promotion of health, physique, and welfare, at any rate within each of the bigger city schools. I remember hearing Sir William McKechnie, formerly head of the Scottish Education Department, coin a Greek word that meant "teacher, physician, and mentor." I ,am sure that teachers are eager to play• all three parts.
Maternity and CMId Welfare The demand on indoor accommodation for confinemerit, which was rapidly increasing before the war, has been intensified and is now very difficult to meet. Fear of raids, the black-out, and a shortage of midwives have contributed to the pressure, but I am convinced that women will increasingly prefer to be confined in an institution rather than at home. This tendency is one to be encouraged and provided for, and steps should be taken to include further accommodation for maternity as part of the new hospital policy. As regards the maternity service, the numbers attending the ante-natal clinics have tended to increase rather than to diminish. It may be inferred that what women most desire is ante-natal care associated with indoor provision for the confinement. Infant life suffered from the two cold spells that occurred in the early months "of 1940 and 1941 and from the whooping-cough epidemic in 1940-41; deaths due to pneumonia, bronchitis, and convulsions rose in consequence. This was the general experience according to the statistical returns recently issued for Scotland.* In this publication it is stated that there was a considerable rise in the number of deaths due to premature birth, the increase being from 809 in the first six months of 1940 to 900 during the same period of this year. Dr. Nora I. Wattle (1941) points out that as between the same two periods in Glasgow infant deaths due to premature birth and other congenital causes underwent an increase equivalent to 17 per thousand births. It is probable that most of this rise is to be attributed to psychological causes during pregnancy, such as anxiety or actual shock. As regards other factors, the whooping-cough epidemic caused a sharp rise in infant mortality; the height of this epidemic coincided with a period of air raids in the early months of the year, and there is evidence that communal shelters played some part in its spread and in determining the onset of pneumonia. Scurvy and the grosser forms of rickets are diseases of the past, but we must be on the watch for their eScottish Vital Statistics, Second Quarte~-, 1941.
1942 return. Only a handful of cases diagnosed as scurvy were reported to me last year. The child-welfare staff has an uneasy feeling that mothers may not be getting enongh vitamin C for their infants. Accordingly the welfare centres are accustomed to make large issues of vitamin C tablets, though no one likes this kind of test-tube feeding. With regard to rickets, the impressions of the child-welfare staff varied as to its incidence. A detailed survey has therefore been made of the records of over 20,000 children under 2 years of age visited by the health visitors during the first three months of 1939 and 1941. This survey shows (a) that the incidence of rickets for the city as a whole was actually smaller during the latter period, i . e . , under war-time conditions; (b) that there was a fractional increase of mild rickets in certain of the poorer localities. These cases are occurring among families whose standards are low and who learn little or nothing by experience. Cod-liver oil is widely distributed, though not all mothers to whom it is issued actually give it to their children. It may be regarded as a happy circumstance that rickets has been so far kept in check.
Hospitals The question of hospital provision will emerge as an immediate post-war problem. The Government has recently declared its policy, the object of which is to ensure that "appropriate treatment shall be readily available to every person in need of it." To satisfy this requirement we may presume that much of the new emergency hospital provision will be incorporated in the public health service of the country. With these additions the hospital system will be able in large measure to meet the present unsatisfied demand for more and better treatment facilities. It will be the duty of the major local authorities to secure these advantages for the sick, and for this purpose to co-operate with the voluntary hospitals. At the same time, planning will be necessary in order to ensure that those who require special kinds of treatment will receive it. In practice this means the " region" as the unit area on which to base a sound and orderly hospital policy. What should be the intention of a hospital service ? The report of the Committee on the Scottish Health Services says that " an adequate hospital service is essential for the public health." This dictum implies that a hospital system should take under its wing all forms and stages of sickness and invalidity, providing for them in ways best suited to their needs and without undue delay. This comprehensive definition comprises a number of inter-related problems, among them provision not only for urgent cases, the acute sick, and the illnesses of short duration, but also for the more chronic types of sickness--the latter form a large and important group of patients, who require, it may be, long-continued periods of skilled treatment --greater provision of hospitals of the sanatorium type for more patients than are now treated in this way; provision for the treatment of patients who cannot be nursed at home or who can best be treated in hospital; provision for observation and diagnosis,
PUBLIC HEALTH strongly advocated by medical practitioners; adaptation of the hospital system to the rise and fall of disease and to changing conceptions of treatment. If hospitals are to carry out these curative and preventive functions it will be necessary to end the distinction between voluntary and municipal hospitals whereby treatment in the former is free and charged for in the latter. In my opinion a really effective preventive hospital service cannot be based on a system of payment for services rendered, as regards, at any rate, the great majority of the population. A hospital system which has these purposes in view and sets out to serve the community in the complete sense of the Government's pronouncement is an integral part of public health. I take it that this is the meaning of the pronouncement, and that there is no intention of regarding the hospital service as a separate administrative entity. Detailed suggestions for a practical scheme cannot, of course, be made at this stage and must await investigations of a technical nature. The problems likely to arise are manifold and complex, and no attempt should be made to solve them all at once; many of them can be solved only in the light of experience. A hospital system cannot follow rigid lines or preconceived ideas; indeed, what is most to be feared is injury to its delicate structure by excessive organising zeal. The first considerations will be (a) to relieve many of the existing hospitals from the high pressure under which they work, (b) to meet, as far as possible, such needs as are known to exist, and (c) to make suitable provision for the more highly specialised forms of treatment.
Conelusion The war has accelerated the pace of progress of the social and health services of the count.ry. Two big environmental factors of first importance have come into play--attention to nutrition, and the cessation of chronic unemployment. These are the soundest foundations on which to build up the health of the nation. I have said nothing about housing, because everyone knows that housing progress will be v!gorously renewed as soon as possible. The provision of a large number of hospital beds for casualties has prepared the way for a progressive hospital policy. In other directions, notably as regards maternity and child welfare and the health of school children, prewar standards are not good enough. The war has, in fact, as is apparent on all sides, produced a determination to improve on the past. Promising developments are to hand, but the programme is formidable; how much of it can be put into operation after the w a r , no one can say. But we can certainly look forward to a policy that will have positive health as its aim. RgFlmll~C~/$ LAmLAW, S., and MACFAaLANE,D. (1941). Brit. Med. ~., 2, 436. PICKEN, R. NI. F. (1941). Ibid., t, 744. MELL~,mY, K. (1941). Med. Off., 65, 39. WATrIE, N. I. (1941). Roy. San. Ass. Scotland, Sept., 1941.
85
PUBLIC HEALTH PUBLIC
HEALTH SERVICES THE WAR *
IN
By SIR ALEXANDER MACGREGOR, O.B.E., M.D., LL.D., F.R.F.P.S.GLAS., J.P.,
Medical O~fcer of Health, Glasgow I am deeply sensible of the high honour which the Society of Medical Officers of Health has conferred on me by appointing me its President. In assuming this high office, I must take this, the first, opportunity of thanking my predecessor, Dr. F. T. H. Wood, for undertaking a second year of office, because I know that he carried on during a very difficult period. I am sure the members of the Society are most grateful to him for this service, as well as for the unrivalled knowledge of public health affairs which he has long placed, and will, I hope, continue to place at their disposal. I am the third holder of this office to hail from Scotland. Dr. A. K. Chalmers held it in 1913, when I was a junior member of his staff. Since his day there has been almost a revolution in public health thought and practice in both our countries, although there are some differences in our respective powers and in the manner of conducting our affairs. In England and Wales you have your great Public Health Act of 1936, while we in Scotland are still waiting for a similar Act, delayed owing to the war. Perhaps we will improve upon it, on the principle of the game of leap-frog. Now that the whole country is on the eve of further advances in public health, it is gratifying to know that the chiefs of our respective services, Sir Wilson Jameson and Dr. Andrew Davidson, have arranged to co-operate with each other in the consideration of our common problems and to encourage a better two-way traffic of knowledge and ideas than has obtained in the past. The public health service occupies a highly responsible place in the war effort; it is passing through a period of great activity and is doing its best to meet all the demands made upon it. New functions have been acquired, and many difficult problems have arisen involving changes in method and outlook, so that the service has largely outgrown its former character and scope. At the same time it is gaining a wealth of new experience which will be of the greatest value in the future; indeed, it may be said that the positive health policy which was slowly evolving in pre-war times has begun to assume a much clearer outline. The functions of public health departments in these days group themselves under three main heads. First, there are the new special emergency services working in close association with or grafted on to public health administration. Secondly, there are the normal health activities adapted and expanded to meet conditions arising out of the war the pre-war problems of health in a new setting. Thirdly, post-war problems are pressing for attention, on which our experience of what is happen=. • Presidential Address to the 8ociety of Medical Officers of Health, November 21st, 1941.
ing now will have an important bearing, because it seems clear that the foundations of future advances in the sphere of public health and social medicine are even now being laid. No one regrets more than I do the curtailment of our opportunities for discussion of our joint affairs, as a result of which I am somewhat out of touch with public health developments in other parts of the country. I shall therefore ask ),our indulgence if I draw largely on local experience in the following remarks on one or two topics which I have chosen from the three heads I have mentioned. A i r R a i d Preoautions Medical officers of health and their staffs are deeply engrossed in the immediate concerns of the war. For the past two years local authorities have carried out big and exacting Government programmes for the health and safety of those on the home front. Many new and unaccustomed duties, both executive and advisory, have been undertaken by public health departments. Much of this work is of a purely emergency kind, such as the organisation of the firstaid and casualty service and co-operation with the Government in many other activities incidental to the war effort--for instance, the emergency hospital scheme, recruitment of nurses, the evacuation arrangements (which have thrown special responsibilities on receiving areas), health and sanitation in shelters and rest centres, salvage of foodstuffs, and sanitary measures following air raids. A quite extraordinary amount of time and energy has been expended on these duties by public health officers throughout the country, not without many anxious and difficult moments. I have specially mentioned these aspects of civil defence, because I am sure the Society will wish to pay a warm tribute to all branches of our public health and sanitary staffs for the effective manner in which they have served the community, as well as for the hard work cheerfully undertaken in the conduct of these special war services in addition to their ordinary duties, very often in defiance of all risks and dangers. It has not been easy for them to preserve a due balance between civil defence requirements and those of public health, but they realise, I am sure, that morale in time of war is much heightened by the confidence which the public reposes in both these aspects of their work. Health visitors in particular, from the closeness of their contact with the homes and daily lives of the people, are assisting in no small degree to sustain the spirit of the nation. It is from them that medical officers of health derive much of their insight into the welfare of families, particularly the condition of the children. The Society will also wish to recognise the indebtedness of the casualty service to medical practitioners throughout the country, who have been eager to take a place in them whenever occasion required. Most of us have had experience of the casualty service in action, and can bear witness to the high courage and resourcefulness under fire shown by the large army of volunteers who have enrolled themselves in this service; their keenness to serve when called upon has been beyond all expectation.
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PUBLIC HEALTH I sometimes wonder whether a way could be found to attract some at least of these volunteers into social work after the war. Many of them would give as valuable service to the community in peace as they are now giving in time of war.
Health and the War I think it is correct to say that the health of the people has been better than was in fact expected, in spite of the new factors which the war has introduced, such as new dispositions of population, overcrowding, the black-out, hard work, and other influences. It is true that certain wide movements of sickness and mortality have taken place concurrently with the war, though not attributable to it. For instance, a wave of diphtheria has been passing over various parts of the country and its force is not yet spent; an epidemic of whooping-cough of quite unusual magnitude occurred in 1940-41 with severe consequences to infants and young children; outbreaks of paratyphoid fever have become more frequent. During the early months of 1940, and again in 1941, prolonged spells of cold weather increased the incidence and mortality due to pneumonia and bronchitis among the elderly and the very young. Professor R. M. F. Picken (1941), in his striking exposition of the effect of a hard winter in London, relates the kind of experience to which we in Scotland are more accustomed on account of the greater vagaries of our northern climate. It would, I think, be in accord with public health experience of the variations of disease from year to year to conclude that these major trends of sickness had little, if anything, to do with conditions arising out of the war. On the other hand, present conditions may be regarded as contributing to an increased incidence of tuberculosis, a restless behaviour of cerebrospinal fever, and a " considerable rise in the number of deaths due to premature birth" as recently recorded in Scottish Vital Statistics, which will be referred to later. Tuberculosis of the lungs and, to a much less extent, non-pulmonary tuberculosis have been rising in Glasgow during the past two years, as is also the case elsewhere. On looking closely at the position in Glasgow, we find that notifications of pulmonary tuberculosis during 1940 increased by about 20 per cent. over the 1939 figure, while the death rate rose very much to the same extent. Comparing 1941 with 1940, it is estimated, on the basis of cases notified during the first ten months, that the incidence for this year will be only 8 per cent. in excess of that for 1940, while the death rate will not be greater. Thus the sharp initial rise that took place in 1940 has been followed by a definite slowing down of the rate of increase of pulmonary tuberculosis. This rise relates almost entirely to males between 15 and 45 and to females between 15 and 35 years of age. These are the working ages and the ages when tuberculosis most often declares itself. There are probably one or two reasons for this increase, but the main reason is to be found in the entry of large numbers of young people into employment; the probability is that an infection that would have been resisted in normal times gains the upper hand. Laidlaw and 82
~ANUARY Macfarlane (1941) attribute this rise to a combination of long hours, overtime, strain, and ill-spent leisure. I may next refer to some disorders in which environmental factors act as predisposing causes. Unemployment is generally recognised to be a fertile source of subnormal health or of actual mental or bodily illhealth. Where social conditions are such that work and wages are plentiful, a reduced incidence of those ill-defined mental and physical disorders that are apt to be engendered by an aimless life may confidently be expected. The evidence available supports this view. If to these social advantages be added a high purpose in life, the general effect is such as to afford an explanation of the fact much commented u p o n - namely, the surprisingly small incidence of neuroses in spite of conditions that might have been expected to produce them in considerable volume. Present-dav conditions have, in fact, greatly reduced the prevai'ence of these ailments, especially among the male population. What this experience means is that progress towards social security is progress towards better health.
Food and the War The most outstanding of the health measures that have come into operation are those dealing with the food supply. The Ministry of Food, in spite of great difficulties, has shown the utmost wisdom in its determination to bring within reach of all the staple articles of diet and to make available to those who need it moat the right kind of food--as, for instance, milk and the protective foods for young children, and for nursing and expectant mothers. Canteens for industrial workers are a long-overdue health measure and should become permanent; they have an important bearing on the relation between housing and industry. Whatever view may ultimately be taken of communal feeding, I hope that the industrial canteen and the school meal have come to stay. These and other practical provisions, to which should be added the stimulus that has been given to the spread of knowledge of food values and to the teaching of cookery, constitute a group of measures applied at the very source of national health and well-being. As the work that the Ministry of Food is now doing in these ways, which may be described as anticipatory and preventive, is of such immense value to the community, I fervently hope that when peace returns it will be found possible to retain in being the Ministry or its equivalent as an essential health service, and so make permanent what would be in effect the greatest because the most beneficial of all the health services. Family catering is a responsible business in these days, and it is not easy to apportion a proper share of the available foods to each member of the family. Restrictions due to rationing and price are perhaps most felt in industrial areas, while families with young children have had to make some difficult adjustments. Those of us who are watching closely the effect of food control will have observed a number of changes for the better in food habits. In my experience there is no doubt that the manner in which the
1942 Ministry of Food is handling the food situation is making a deep impression on the attitude of the people to the common articles of diet. The childwelfare service is called upon to advise mothers on the feeding of children and to keep an eye upon household dietaries. In carrying out these duties, the health visitors, who are in a position to report on the food habits of the average householder, have noted the following broad tendencies. The National Milk Scheme has created a definite "milk psychology"; more milk is consumed than ever before, and mothers agree that this is one of the best services that has been rendered to their children. They view with great anxiety the recent cut in supplies, which reduces the amount of non-priority milk available. Porridge has returned to favour in a large way. The nutritious herring, which was for some reason difficult to popularise, is in great demand. A new impetus has been given to the consumption of vegetables and fruit, which appear to have become increasingly popular for their own sake. It is stated that since the last war the country had increased its consumption of fruit by 90 per cent., of vegetables by 60 per cent., and of milk by 50 per cent. Thus, it may be said that the exigencies of war and the food policy of the Government have accelerated the progress that had been recorded in the consumption of essential foodstuffs. These are solid advances in the national dietary; they represent definite progress towards a more wholesome food r~gime, a progress that we may hope will never be checked or reversed, because we know what the improved feeding of the pre-war years has already done for the health of the people. We now see going on a great experiment in social medicine, conducted though it is in the hard school of war, leading to the formation of more wholesome feeding habits and to a knowledge of food values aided by persistent propaganda, combined with a national policy which is making the most essential of the foodstuffs available to all in the homes of the people, in canteens, and in schools.
Henlth in the Schools Observations on the physical condition of school children are reassuring. Education was at first completely dislocated by the big exodus of children from the cities to the country. When a large percentage of the evacuees subsequently returned school attendance was gradually restored, but under a greatly modified r6gime. In these circumstances, while general supervision of school children was maintained it was not possible to continue the routine measurements of height and weight--at any rate to an extent that would make them strictly comparable with those of former years. I may, however, mention certain measurements taken in the Glasgow schools between September 1940 and April 1941 of some 6-7,000 boys and the same number of girls at the ages of 5 and 13. All the measurements were an improvement upon those for 1939, particularly in the case of school entrants. Although evacuation and interference with school attendance disturbed the representative nature
PUBLIC HEALTH of these groups, the results may be accepted as implying that school children have lost none of the improved physical condition that has been so marked a feature in recent years. One or two influences on school children caused by the emergency seem well worth mentioning. First, it was found that absenteeism from school meant absenteeism also from the clinics, so that defects that would normally have been noticed and rectified went undetected and untreated even though a follow-up system was set up. This experience showed ver,¢ clearly how much the school medical service is dependent for its success on the care and vigilance of the teachers. Secondly, factors that conduce to misdirected energy and juvenile delinquency have been intensified, leading to an increased need for child guidance among other measures advocated to counteract this tendency. Thirdly, it was discovered that more children had verminous infestation of the head than was previously suspected, and that with the aid of a comb and magnifying glass the presence of nits or lice or both could be detected in at least 40 per cent. of school children; in some schools the figure was still higher. This is much the same figure ~s Kenneth Mellanby (1941) found in his special inquiry in England. Vermin on body clothing--a worse form of infestation that used to be very common--is now relatively infrequent, but the head louse has obtained a fresh lease of life protected by the new feminine styles of hair, among which it can live and multiply as an unnoticed or accepted tenant. When this information was passed on to parents it was received with varied emotions--astonishment, disbelief, resentment, indifference. This discovery is a forcible reminder that standards of cleanliness are still too low. Conditions such as verminous infestation and scabies need not and should not spread to the extent they do. This is surely a matter for parents themselves to deal with, and it is quite wrong that responsibility for low standards of cleanliness should be laid on public health departments. This recent experience strengthens the view that health and welfare in schools could be further improved by making them a more clearly defined branch of education. In this opinion I may say that the Director of Education in Glasgow, Mr. R. M. Allardyce, and myself are agreed, while the teachers, whose interest has now been fully awakened by social events and by the turmoil of evacuation, are eager to co-operate and to help forward a policy in which they would be active partners not only in health education but also in the care and welfare of their charges. Towards the close of last year the Education Committee in Glasgow decided to try out an important experiment in six of the bigger primary schools by arranging for the senior woman assistant to give her whole time to personal hygiene, with the help of a lay assistant, the duties to include the welfare work of the schools (i.e., clothing, milk, meals, and cleanliness). This experiment has been an unqualified success. It was natural that at the outset of the scheme cleanliness and freedom from vermin should be the first objective, and these teachers, along with their lay helpers, devoted their attention specially
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PUBLIC HEALTH to this problem, interviewing parents, inspecting the children, and enlisting their interest in correct habits and behaviour as only teachers can. Infested heads and dirty clothing were dealt with on the spot. As a result of their work during the first three or four months they were able to report an outstanding improvement in the percentage of children who could be classed as "clean and well cared for," the term " c l e a n " meaning complete freedom from any sign of nits or vermin in the head. In the case of boys, the percentage so classified rose from 55 per cent. to about 80 per cent.; in the case of girls, from 30 per cent. to 65 per cent., a very high standard being adopted. More particularly the incidence of infestation fell as follows: (a) children with verminous heads, from 5 to 2 per cent. in the case of boys, and from 14 to 4 per cent. in the case of girls; (b) children with nits only in the hair, from 30 to 12 per cent. in the case of boys, and from 50 to 25 per cent. in the case of girls.. It is not, of course, intended that this should be the sole function of those taking part in the scheme. Besides giving practical instruction in personal hygiene and assisting actively in its practice, they keep a watchful eye on the general health of the scholars, co-operating with the other teachers and with the school doctors and nurses. They are also responsible for selecting and recommending pupils for free meals and for free boots and clothing. Apart from this experiment, a special short trial course of piactical instruction with demonstrations was given to some sixty senior women assistants, so as to acquaint them with the kind of health problems they would be likely to encounter in their work. A further instance of this teacher-pupil relationship is seen in the problem of child guidance. Much consideration is being given throughout the country to the best methods of administering and staffing this valuable and growing service. In some quarters it is considered that the supervision of children should be carried out at a clinic staffed by medical specialists and specially trained social workers. As this is a controversial topic it may be of interest if I mention the basis of the scheme as operated in Glasgow. Child guidance is regarded as an integral part of the education system, the key workers in it being trained teacher psychologists who also carry out the domiciliary inquiries and home supervision. The medical and psychiatric side is under thec0ntrol of the Education Health Service, and at each stage of development there is close co-operation and consultation between the education and the health administrations. The aim is to preserve an unbroken link between the school, the child-guidance clinic, and the residential home for more difficult cases, treatment being in the hands of teacher psychologists in co-operation with psychiatrists. This scheme was inaugurated after careful consideration, and it was regarded as fundamental that the staff conducting it should possess a background of teachin~ experience as well as a training in psychology. O f course, everything depends on careful choice of personnel. From the results that are being obtained I am fully convinced b a t these arrangements are soundly conceived and are working admirably in practice. 84
~ANUARY I have dwelt upon these developments because we in Glasgow are quite convinced that we are proceeding here on the right lines. Health education, physical fitness, welfare, care of health, child guidance--the more these measures evolve from within the schools themselves the more successful will be the results. I notice that the Board of Education and the Scottish Education Department are engaged in the preparation of plans to renrganise education after the war. Among these plans I should like to see a definite organisation for the promotion of health, physique, and welfare, at any rate within each of the bigger city schools. I remember hearing Sir William McKechnie, formerly head of the Scottish Education Department, coin a Greek word that meant "teacher, physician, and mentor." I ,am sure that teachers are eager to play• all three parts.
Maternity and CMId Welfare The demand on indoor accommodation for confinemerit, which was rapidly increasing before the war, has been intensified and is now very difficult to meet. Fear of raids, the black-out, and a shortage of midwives have contributed to the pressure, but I am convinced that women will increasingly prefer to be confined in an institution rather than at home. This tendency is one to be encouraged and provided for, and steps should be taken to include further accommodation for maternity as part of the new hospital policy. As regards the maternity service, the numbers attending the ante-natal clinics have tended to increase rather than to diminish. It may be inferred that what women most desire is ante-natal care associated with indoor provision for the confinement. Infant life suffered from the two cold spells that occurred in the early months "of 1940 and 1941 and from the whooping-cough epidemic in 1940-41; deaths due to pneumonia, bronchitis, and convulsions rose in consequence. This was the general experience according to the statistical returns recently issued for Scotland.* In this publication it is stated that there was a considerable rise in the number of deaths due to premature birth, the increase being from 809 in the first six months of 1940 to 900 during the same period of this year. Dr. Nora I. Wattle (1941) points out that as between the same two periods in Glasgow infant deaths due to premature birth and other congenital causes underwent an increase equivalent to 17 per thousand births. It is probable that most of this rise is to be attributed to psychological causes during pregnancy, such as anxiety or actual shock. As regards other factors, the whooping-cough epidemic caused a sharp rise in infant mortality; the height of this epidemic coincided with a period of air raids in the early months of the year, and there is evidence that communal shelters played some part in its spread and in determining the onset of pneumonia. Scurvy and the grosser forms of rickets are diseases of the past, but we must be on the watch for their eScottish Vital Statistics, Second Quarte~-, 1941.
1942 return. Only a handful of cases diagnosed as scurvy were reported to me last year. The child-welfare staff has an uneasy feeling that mothers may not be getting enongh vitamin C for their infants. Accordingly the welfare centres are accustomed to make large issues of vitamin C tablets, though no one likes this kind of test-tube feeding. With regard to rickets, the impressions of the child-welfare staff varied as to its incidence. A detailed survey has therefore been made of the records of over 20,000 children under 2 years of age visited by the health visitors during the first three months of 1939 and 1941. This survey shows (a) that the incidence of rickets for the city as a whole was actually smaller during the latter period, i . e . , under war-time conditions; (b) that there was a fractional increase of mild rickets in certain of the poorer localities. These cases are occurring among families whose standards are low and who learn little or nothing by experience. Cod-liver oil is widely distributed, though not all mothers to whom it is issued actually give it to their children. It may be regarded as a happy circumstance that rickets has been so far kept in check.
Hospitals The question of hospital provision will emerge as an immediate post-war problem. The Government has recently declared its policy, the object of which is to ensure that "appropriate treatment shall be readily available to every person in need of it." To satisfy this requirement we may presume that much of the new emergency hospital provision will be incorporated in the public health service of the country. With these additions the hospital system will be able in large measure to meet the present unsatisfied demand for more and better treatment facilities. It will be the duty of the major local authorities to secure these advantages for the sick, and for this purpose to co-operate with the voluntary hospitals. At the same time, planning will be necessary in order to ensure that those who require special kinds of treatment will receive it. In practice this means the " region" as the unit area on which to base a sound and orderly hospital policy. What should be the intention of a hospital service ? The report of the Committee on the Scottish Health Services says that " an adequate hospital service is essential for the public health." This dictum implies that a hospital system should take under its wing all forms and stages of sickness and invalidity, providing for them in ways best suited to their needs and without undue delay. This comprehensive definition comprises a number of inter-related problems, among them provision not only for urgent cases, the acute sick, and the illnesses of short duration, but also for the more chronic types of sickness--the latter form a large and important group of patients, who require, it may be, long-continued periods of skilled treatment --greater provision of hospitals of the sanatorium type for more patients than are now treated in this way; provision for the treatment of patients who cannot be nursed at home or who can best be treated in hospital; provision for observation and diagnosis,
PUBLIC HEALTH strongly advocated by medical practitioners; adaptation of the hospital system to the rise and fall of disease and to changing conceptions of treatment. If hospitals are to carry out these curative and preventive functions it will be necessary to end the distinction between voluntary and municipal hospitals whereby treatment in the former is free and charged for in the latter. In my opinion a really effective preventive hospital service cannot be based on a system of payment for services rendered, as regards, at any rate, the great majority of the population. A hospital system which has these purposes in view and sets out to serve the community in the complete sense of the Government's pronouncement is an integral part of public health. I take it that this is the meaning of the pronouncement, and that there is no intention of regarding the hospital service as a separate administrative entity. Detailed suggestions for a practical scheme cannot, of course, be made at this stage and must await investigations of a technical nature. The problems likely to arise are manifold and complex, and no attempt should be made to solve them all at once; many of them can be solved only in the light of experience. A hospital system cannot follow rigid lines or preconceived ideas; indeed, what is most to be feared is injury to its delicate structure by excessive organising zeal. The first considerations will be (a) to relieve many of the existing hospitals from the high pressure under which they work, (b) to meet, as far as possible, such needs as are known to exist, and (c) to make suitable provision for the more highly specialised forms of treatment.
Conelusion The war has accelerated the pace of progress of the social and health services of the count.ry. Two big environmental factors of first importance have come into play--attention to nutrition, and the cessation of chronic unemployment. These are the soundest foundations on which to build up the health of the nation. I have said nothing about housing, because everyone knows that housing progress will be v!gorously renewed as soon as possible. The provision of a large number of hospital beds for casualties has prepared the way for a progressive hospital policy. In other directions, notably as regards maternity and child welfare and the health of school children, prewar standards are not good enough. The war has, in fact, as is apparent on all sides, produced a determination to improve on the past. Promising developments are to hand, but the programme is formidable; how much of it can be put into operation after the w a r , no one can say. But we can certainly look forward to a policy that will have positive health as its aim. RgFlmll~C~/$ LAmLAW, S., and MACFAaLANE,D. (1941). Brit. Med. ~., 2, 436. PICKEN, R. NI. F. (1941). Ibid., t, 744. MELL~,mY, K. (1941). Med. Off., 65, 39. WATrIE, N. I. (1941). Roy. San. Ass. Scotland, Sept., 1941.
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