- Email: [email protected]
Tuberculosis among African Natives
1935.
PUBLIC HEALTH.
they might be, and whether it would be possible to lay more emphasis in school curricula on subjects which would enable those taught to think and act for themselves in later life in matters of health. Recognising that these are not easy or simple or local questions, he recommends that they should be examined from a national angle. From the report it is very clear that definite views are held on the medicosocial possibilities of school life. Further, Dr. Macgregor seeks a re-orientation of the health services on more preventive lines. As each of the existing medical services is reviewed, a strong case is built up in support of the view that public health in its present chaotic and partial form is lacking in effectiveness because of the absence of an adequate medical and home nursing service. The weaknesses of the maternity and child welfare movement, of the education health service (which in Glasgow and in most parts of Scotland, it is explained, is administered by the public health department), of the poor law medical service, and of the clinic system generally, he opines can be resolved only by a general medical service with prevention as its primary aim. The point is made that the general medical practitioner of the future will have a definite place in the public health structure and organisation, while the whole field of preventive medicine would be covered by harmonious co-operation without rivalry or misunderstanding. The first concern of such a service would be with the health of children. This, most will readily admit. Little real advance is possible until these gaps are filled and the health services are integrated both on the preventive and curative sides. If these views are sound it follows that the health authority would be the administrative body and that the insurance committee as a provider of medical services would disappear. At any rate, the insurance committee as at present constituted, he holds, cannot be regarded as a health authority. Reviewing the hospital problem, Dr. Macgregor concludes that the general hospitals will riot reach their full degree of usefulness until a domiciliary medical and especially a nursing service has been provided. Hospital provision would then become more efficient, less wasteful, and more serviceable to the medical practitioner. The suggestion is made that the sections of the Local Government Act relating to provision for the sick generally should be made compulsory, and that hospital provision should be viewed from a regional rather than from a local standpoint so as to prevent
279
unnecessary duplication of special services and the provision of unnecessary or redundant accommodation. As regards the outdoor medical service, the question is asked whether the present position should not be regarded as a temporary phase of medical administration which will end when a solution has been reached of the larger problem of which it is a part, i.e., medical provision for the community. As indicated, this report is an essay in preventive medicine. Of its kind, it is unique and of an astounding completeness and a remarkable thoughtfulness. Its preparation must have involved vast labour as well as thought, and its • study will prove stimulating and will bring suggestion and provoke to thought. That it may provoke to action also is a hope sincerely to be entertained.
*
*
•
•
*
Tuberculosis Among African Natives. E reports to the Medical Research T HCouncil on Studies of Tuberculosis among African Natives appear as a supplement- to the January number of Tubercle. The Bahr el Ghazel Province, Southern Sudan, is dealt with by Captain S. M. Burrows, R.A.l\I.C., the Tanganyika Territory by Dr. Charles w: lcocks, and Zanzibar by Dr. R. J. Matthews . In a valuable introduction, Professor S. Lyle Cummins, C.B ., C.M.G., who edited these collected papers, mentions the apprehensions as to the future of South African races in relation to tuberculosis spread by the penetration of tuberculised European and Asiatic settlers, and fostered by the substitution of industrial aggregation for the relative isolation ;f tribal life; apprehensions intensified by experience in the Great War, and of the tuberculisation of natives employed on the Rand mines. The districts studied present varying conditions; one is a coastal area long Europeanised, one an inland district more recently Europeanised, while one district is inland and almost isolated. The habits of the natives and the lives they lead have been carefully investigated and a number of Mantoux cutaneous tests have been made ; 3,662 natives tested in Bahr el Ghazel revealed 32'7 per cent. of positive reactors, in Tanganyika 500 tests yielded about 50 per cent. positive, arid in Zanzibar some GO per ·London: John Bale, Sons and Danielsson, Ltd. Price 78. 6d.
280
PUBLIC HEALTH.
cent. of 985 tests were positive. The experiments carried 011t were not uniform, but the difficulties and prejudices encountered differed both in nature and extent, so that no one would expect anything like the precision of a laboratory experiment. Nevertheless, tuberculosis workers will be grateful for the varied and useful informa tion here presented .
It is interesting to note that the figures in these reports substantiate the observation alread y noted among th e natives of the Rand mines that a higher cutaneous sensitivity is often associated with a low immunising response, and the cutaneous sensitivity found is much higher than in Europeans. .The fullest report of the series deals with Zanzibar, where it is remarked that notification as at present carried out is very ineffective . Susceptibility is found to vary in the inverse ratio to the experience of infection but directl y with exposure to mass infection. The purdah system among Hindoo .residents p~o motes infection and lowers resistance, while a deficient dietary prejudices recovery in all three districts. The report contains a valuable quotation, concerning prevention and treatment, from a memorandum of the Medical Research Council: "It is through the sympathetic adaptation of native ideas and methods to the uses of modern hygiene, rather than the abrupt substitution of European regulations for native customs, that success is most likely to be achieved." Small isolated settlements for the tuberculous are advocated rather than expensive institutions. The difficulties of early diagnosis in Africa are in some respects similar to those in this country and the acute cases are often silent, but radiographic examination in Africa is more difficult to obtain. It must be admitted that there are districts in this country where the value of this method of examination is not yet sufficiently appreciated. Dr. Wilcocks suggests that there may be acid-fast organisms, other than the bacillus of Koch, capable of playing a pathogenic role among African populations, but exact proof of the reflection is not yet forthcoming . Great difficulty was found in keeping alive the perimental animals, and it is suggested that, in future, cultural methods might be tried as an alternative. An innovation of Dr. Wilcocks was the confirmation of diagnosis in certain cases by gland puncture a procedure which
ex.
might be more widely employed with advan., tage. The concluding remarks in Professor Cummins' introduction deserve quotation: " An imperial race such as our own Owes at least this debt to its subject populations; that. even if we do introduce our infections along with our culture, we offer, at the same time. the full fruits of our more advanced civilisa. tion in the provision of facilities for preven~ tion and treatment."
•
•
•
•
•
Public Health and Public Assistance in London.
T wo
reports recently issued by the London County Council deal with the work done in 1933 in relation to Public Health and Public Assistance. The main bulk of the former. is devoted to housing, memoranda by the Comptroller of the Council and the Valuer containing discussions of the accounts and statistics, while in addition a mass of mOst interesting and useful information is given with regard to progress made in relation to slum clearance and rehousing, the development of housing estates, grants to borough Councils and so on. Apart from housing, other matter~ considered include the hospital and other services transferred under the provisions of the Local Government Act, 1929; public health generally, and main drainage. So far as hospitals are concerned. the accommodation for patients, it is shOwn . amounted to 41,068 beds. Extensions in a number of directions were, however. under consideration, great additions and improvements at the fever hospitals particularly being Con_ Under the heading "Various ternplated. Arrangements at Hospitals," certain matters in relation to ante-natal services and puerperal fever cases are discussed, and it is indicated that as the result of a satisfactory trial in 14 general hospitals of the use of chloroform in the form of crushable capsules for normal maternity cases, arrangements have been authorised for the use of these capsules in the Council's hospitals on the understanding that the use is rigidly restricted to normal labOur only. Precautions are to be taken to ensure that the capsules are administered under medical direction by the maternity sisters or their deputies.
.
-Annual Report of the Council, 1933, Vo-;-ZNo. 3102. London: P. S. King & Son, Ltd: l~: Great Smith Street, S.W.1. Price Is. ..
PUBLIC HEALTH.
they might be, and whether it would be possible to lay more emphasis in school curricula on subjects which would enable those taught to think and act for themselves in later life in matters of health. Recognising that these are not easy or simple or local questions, he recommends that they should be examined from a national angle. From the report it is very clear that definite views are held on the medicosocial possibilities of school life. Further, Dr. Macgregor seeks a re-orientation of the health services on more preventive lines. As each of the existing medical services is reviewed, a strong case is built up in support of the view that public health in its present chaotic and partial form is lacking in effectiveness because of the absence of an adequate medical and home nursing service. The weaknesses of the maternity and child welfare movement, of the education health service (which in Glasgow and in most parts of Scotland, it is explained, is administered by the public health department), of the poor law medical service, and of the clinic system generally, he opines can be resolved only by a general medical service with prevention as its primary aim. The point is made that the general medical practitioner of the future will have a definite place in the public health structure and organisation, while the whole field of preventive medicine would be covered by harmonious co-operation without rivalry or misunderstanding. The first concern of such a service would be with the health of children. This, most will readily admit. Little real advance is possible until these gaps are filled and the health services are integrated both on the preventive and curative sides. If these views are sound it follows that the health authority would be the administrative body and that the insurance committee as a provider of medical services would disappear. At any rate, the insurance committee as at present constituted, he holds, cannot be regarded as a health authority. Reviewing the hospital problem, Dr. Macgregor concludes that the general hospitals will riot reach their full degree of usefulness until a domiciliary medical and especially a nursing service has been provided. Hospital provision would then become more efficient, less wasteful, and more serviceable to the medical practitioner. The suggestion is made that the sections of the Local Government Act relating to provision for the sick generally should be made compulsory, and that hospital provision should be viewed from a regional rather than from a local standpoint so as to prevent
279
unnecessary duplication of special services and the provision of unnecessary or redundant accommodation. As regards the outdoor medical service, the question is asked whether the present position should not be regarded as a temporary phase of medical administration which will end when a solution has been reached of the larger problem of which it is a part, i.e., medical provision for the community. As indicated, this report is an essay in preventive medicine. Of its kind, it is unique and of an astounding completeness and a remarkable thoughtfulness. Its preparation must have involved vast labour as well as thought, and its • study will prove stimulating and will bring suggestion and provoke to thought. That it may provoke to action also is a hope sincerely to be entertained.
*
*
•
•
*
Tuberculosis Among African Natives. E reports to the Medical Research T HCouncil on Studies of Tuberculosis among African Natives appear as a supplement- to the January number of Tubercle. The Bahr el Ghazel Province, Southern Sudan, is dealt with by Captain S. M. Burrows, R.A.l\I.C., the Tanganyika Territory by Dr. Charles w: lcocks, and Zanzibar by Dr. R. J. Matthews . In a valuable introduction, Professor S. Lyle Cummins, C.B ., C.M.G., who edited these collected papers, mentions the apprehensions as to the future of South African races in relation to tuberculosis spread by the penetration of tuberculised European and Asiatic settlers, and fostered by the substitution of industrial aggregation for the relative isolation ;f tribal life; apprehensions intensified by experience in the Great War, and of the tuberculisation of natives employed on the Rand mines. The districts studied present varying conditions; one is a coastal area long Europeanised, one an inland district more recently Europeanised, while one district is inland and almost isolated. The habits of the natives and the lives they lead have been carefully investigated and a number of Mantoux cutaneous tests have been made ; 3,662 natives tested in Bahr el Ghazel revealed 32'7 per cent. of positive reactors, in Tanganyika 500 tests yielded about 50 per cent. positive, arid in Zanzibar some GO per ·London: John Bale, Sons and Danielsson, Ltd. Price 78. 6d.
280
PUBLIC HEALTH.
cent. of 985 tests were positive. The experiments carried 011t were not uniform, but the difficulties and prejudices encountered differed both in nature and extent, so that no one would expect anything like the precision of a laboratory experiment. Nevertheless, tuberculosis workers will be grateful for the varied and useful informa tion here presented .
It is interesting to note that the figures in these reports substantiate the observation alread y noted among th e natives of the Rand mines that a higher cutaneous sensitivity is often associated with a low immunising response, and the cutaneous sensitivity found is much higher than in Europeans. .The fullest report of the series deals with Zanzibar, where it is remarked that notification as at present carried out is very ineffective . Susceptibility is found to vary in the inverse ratio to the experience of infection but directl y with exposure to mass infection. The purdah system among Hindoo .residents p~o motes infection and lowers resistance, while a deficient dietary prejudices recovery in all three districts. The report contains a valuable quotation, concerning prevention and treatment, from a memorandum of the Medical Research Council: "It is through the sympathetic adaptation of native ideas and methods to the uses of modern hygiene, rather than the abrupt substitution of European regulations for native customs, that success is most likely to be achieved." Small isolated settlements for the tuberculous are advocated rather than expensive institutions. The difficulties of early diagnosis in Africa are in some respects similar to those in this country and the acute cases are often silent, but radiographic examination in Africa is more difficult to obtain. It must be admitted that there are districts in this country where the value of this method of examination is not yet sufficiently appreciated. Dr. Wilcocks suggests that there may be acid-fast organisms, other than the bacillus of Koch, capable of playing a pathogenic role among African populations, but exact proof of the reflection is not yet forthcoming . Great difficulty was found in keeping alive the perimental animals, and it is suggested that, in future, cultural methods might be tried as an alternative. An innovation of Dr. Wilcocks was the confirmation of diagnosis in certain cases by gland puncture a procedure which
ex.
might be more widely employed with advan., tage. The concluding remarks in Professor Cummins' introduction deserve quotation: " An imperial race such as our own Owes at least this debt to its subject populations; that. even if we do introduce our infections along with our culture, we offer, at the same time. the full fruits of our more advanced civilisa. tion in the provision of facilities for preven~ tion and treatment."
•
•
•
•
•
Public Health and Public Assistance in London.
T wo
reports recently issued by the London County Council deal with the work done in 1933 in relation to Public Health and Public Assistance. The main bulk of the former. is devoted to housing, memoranda by the Comptroller of the Council and the Valuer containing discussions of the accounts and statistics, while in addition a mass of mOst interesting and useful information is given with regard to progress made in relation to slum clearance and rehousing, the development of housing estates, grants to borough Councils and so on. Apart from housing, other matter~ considered include the hospital and other services transferred under the provisions of the Local Government Act, 1929; public health generally, and main drainage. So far as hospitals are concerned. the accommodation for patients, it is shOwn . amounted to 41,068 beds. Extensions in a number of directions were, however. under consideration, great additions and improvements at the fever hospitals particularly being Con_ Under the heading "Various ternplated. Arrangements at Hospitals," certain matters in relation to ante-natal services and puerperal fever cases are discussed, and it is indicated that as the result of a satisfactory trial in 14 general hospitals of the use of chloroform in the form of crushable capsules for normal maternity cases, arrangements have been authorised for the use of these capsules in the Council's hospitals on the understanding that the use is rigidly restricted to normal labOur only. Precautions are to be taken to ensure that the capsules are administered under medical direction by the maternity sisters or their deputies.
.
-Annual Report of the Council, 1933, Vo-;-ZNo. 3102. London: P. S. King & Son, Ltd: l~: Great Smith Street, S.W.1. Price Is. ..