Unification of control

Public Health THE

The

JOURNAL

Society of Medical Officers of Health. DECEMBER,

No. 3.

S u b s c r i p t i o n price, 31s. 6d. p e r a n n u m , p o s t f r e e in advance, S i n g l e copies, 2s. 6d., post free.

COINTENT,5.

EDITORIAL--Unification of Control " The Times "

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W i n e s d e n S M A flihs~o~'"

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PAOE 53 55

Dental Defects ............... 0BITU~,RY ..................

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56 56

SPECIAL ARTICLES -d

A Bird's Eye View of Typhoid Fever in London during the last Seventy Years (By W.H.Hamer,

M.A., M.D., lV.R.C.P., D.P.tl., President of the Metropolitan Branch, S.M.O.H.) ...

57

" The Influence of the Placenta in relation to Premature Birth and Ante-Natal Death " (By D. C. Kirkhope, M.D., Ch.M., D.P.H . . . . Dental Defects (By James Wheatley, M.D.,

64

County Mcdical Officer, Shr@shire)... Strangways, L.D.SII Dental Officer,eTorquay) ......... Medical Correspondents (By an Occasio~at Contributor) ...............

Dental Defects (ByLudlow

67 68 70

SOCIETY OF MEDICAL OFFICERS OF HEALTH-Notices .........

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t.--Metropolitan Branch ......... II.--West of England Branch ...... Coancil Meeting ;: . . . . . . . . . . . . . Ordinary Meeting . . . . . . . . . . . . . . . Northern Branch ............ North-Western Brancl3 ............ Midland Branch ............... Eastern Branch ............... Scottish Branch ............... Tuberculosis Group . . . . . . . . . . . . . . . Maternity and Child Welfare Group ......

73 74 74 76 76 79 79 80 81 81 84

Notes from t~; Sra£~i~s--"

(IORREgPONDENgE-Infectivity of Scarlet Fever

Dental Defects

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84 84

t ditorial. UNIFICATION

OF CONTROL.

i d e c r e a t i o n of a Mh~istry of H eal'th, was ~.~n~ doubtedly the result of a popular d e m a n d due to the g e n e r a l conviction that public health a d m i n i s t r a t i o n , bot.h centrally and locally, w a s badly in need of c o - o r d i n a t i o n and r e o r g a n i s a tion. Such a M i n i s t r y w a s claimed to be the first st,'p t o w a r d s the a t t a i n m e n t of unification of control, and a g o o d deal has been accomplished in t h a t direction, but t h e r e is one central imp r o v e m e n t which is very much overdue. The Board of E d u c a t i o n still m a i n t a i n s its hold u p ~

r

OF

1921.

VOL.

XXXV.

the medical inspection of school children, and this condition of affairs is e x e r c i s i n g a m o s t u n f o r t u n a t e result upon the d e v e l o p m e n t not only of the work of medical inspection but also upon the g e n e r a l public health service with which it should by n o w have become an i n t e g r a l part. It will probably be r e m e m b e r e d that when the Ministry of H e a l t h Bill w a s in C o m m i t t e e t h e B o a r d of E d u c a t i o n m a d e s t r e n u o u s efforts to g e t itself excepted from the Bill, but the intentions of P a r l i a m e n t were very definite upon this point and t h e medicaI inspection of school children w a s included a m o n g the spheres of activity to be controlled and absorbed by the Ministry. In spite of its defeat, and in spite of the very clearly expressed wishes of P a r l i a m e n t upon the subjecL the B o a r d of E d u c a t i o n has continued to retain c o n t r o l of the w o r k of medicat inspection, and in the E d u c a t i o n Act, 1921, it has a p p a r e n t l y reestablished to a l a r g e e x t e n t the status quo. It is i m p o r t a n t t h a t t h e position under the E d u c a t i o n Act, t921, should be clearly understood. Section 3 c o n s t i t u t e s the Council as the Local E d u c a t i o n A n t h o r i t y , an entirely satisfactory conditio,a but, unfortunately, section 4 proceeds to establish an education c o m m i t t e e of the council to which all m a t t e r s r e l a t i n g to the exercise by the council of their powers under this A c t shall stand referred. Section 11 makes it the duty o f the local educafion a u t h o r i t y to submit to the B o a r d of E d u c a t i o n schemes for perform.in K their duties with reg4ard to education, but section 16 provides that the p a r t of the scheme r e l a t i n g to medical inspection or treat'meant of sGhool .chiJd?en m u s t be a p p r o v e d by the Ministry of H e a l t h and not the Board of Education. This c o n f o r m s with the Ministry of H e a l t h Act, but the obvious intentions of Parliam e n t at that t i m e are a g a i n nullified by the introduction of the p r o v i s o that the M i n i s t e r of H e a l t h may m a k e a r r a n g e m e n t s with the Board of E d u c a t i o n r e s p e c t i n g the submission and approval of such schemes, and the p o w e r s and duties of the Minister may, under such a r r a n g e me-~lts, be exercised and performed by the Board

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of E d u c a t i o n under such c o n d i t i o n s as th¢ Minister of H e a l t h m a y t h i n k fit. W e contend that the c o n t i n u a t i o n of this proviso, which w a s inserted into the M i n i s t r y of H e a l t h Act purely as a t e m p o r a r y measure, is in direct c o n t r a v e n tioi~ of the intentions of P a r l i a m e n t when p a s s i n g the M i n i s t r y of H e a l t h Act, a n d also t h a t it is a serious obstacle in the w a y of the p r o g r e s s in public health. T h e w o r d i n g of section 80 of the E d u c a t i o n Act, 1921, which a p p e a r s at first s i g h t to be entirely satisfactory, inasmuch as all duties conn e t t e d with medical inspection a n d t r e a t m e n t are placed upon the local e d u c a t i o n a u t h o r i t y , i.e., the local Council, but, u n f o r t u n a t e l y , section causes this d u t y to stand referred to the education committee. Thus a g a i n the spirit of the M i n i s t r y o f I l e a l t h Act is not observed, and the obvious intentions of P a r l i a m e n t when p a s s i n g i)hat Act are b e i n g defied. S i m i l a r obstacles are p r o v i d e d in Section 118 where the strict letter of the M i n i s t r y of H e a l t h A c t is o b s e r v e d b y the substitution of the M i n i s t r y of H e a l t h fdr the B o a r d of E d u c a t i o n , but where the spirit of t h a t Act and the intentions of P a r l i a m e n t a r e defied by the c o n t i n u a t i o n of the p r o v i s o which w a s a g r e e d upon as a t e m p o r a r y m e a s u r e only. T h e time is obviously much o v e r d u e for the whole of the w o r k a n d m a c h i n e r y connected with the medical inspection and t r e a t m e n t of school children to become included in g e n e r a l public health w o r k both centrally and locally. It is not at all difficult to show t h a t its c o n t i n u e d s e p a r a t i o n is a g a i n s t the public interest and is c a u s i n g u n n e c e s s a r y expenditure in m a n y directions. E v e r y a r g u m e n t t h a t w a s used for the c r e a t i o n of the Ministry of H e a l t h m a y be applied with equal force to the i m m e d i a t e inclusion of the medical w o r k of the B o a r d of E d u c a t i o n within the Ministry, and foe the imm.ediate a b s o r p t i o n of this w o r k h)cally by the local public authority. A't the inception of medical inspection of school children there were obvious r e a s o n s why this w o r k stmuld be given to E d u c a t i o n Committees, and all kinds of difficulties m i g h t have been c r e a t e d { f " thlg step had not been taken. Obviously, liowever, such an artificial a r r a n g e m e n t of the w o r k should have been only temp o r a r y , and it is now b e i n g r e a l i s e d that we have paid a b i g price for a v o i d i n g those p r e l i m i n a r y difficulties and for o b t a i n i n g those initi~d advantages. Medical inspection is now an established ai~d a c c e p t e d fact, ;rod there. no kruger remain any real adwtn~cages for k e e p i n g this service

HEALTH.

DEC~tm~E ~,

under the label of education.. On the other h a n d the w o r k is suffering b a d l y o w i n g to the fact that it is not being directed as p a r t of the g r e a t public health machine of the country, and there are signs, moreover, t h a t the p r e s e n t ~[eaction in health m a t t e r s is b e i n g seized upon .as an opportunity for m a k i n g the medical w o r k of education c o m m i t t e e s a m i n o r item in the local education dep a r t m e n t and for p u s h i n g it further into the b a c k g r o u n d . The m e m o r a n d u m recently presented to the County Councils A s s o c i a t i o n on this subjeci by the A s s o c i a t i o n of D i r e c t o r s of Education) should be sufficient to convince the M i n i s t r y of the d a n g e r , as such a m e m o r a n d u m must, necessarily, p r e s e n t the views of the a v e r a g e director only and stop far short of the ideas of the more e x t r e m e members. It is true. t h a t the C o u n t y Councils A s s o c i a t i o n have decided to i g n o r e the m e m o r a n d u m , but there is no doubt that in m o s t a r e a s every effort will be m a d e to secure at least the position set out therein. Already, here and there, an e x t r a o r d i n a r y and farcical state of affairs has been set up, and m a n y directors ha#e succeeded in o u s t i n g the medical officer, from his p r o p e r position as medical a d v i s e r to the e d u c a t i o n c o m m i t t e e and chief a d m i n i s t r a t o r of the scheme for the medical inspection and t r e a t m e n t of children, a n d t h e r e is convincing evidence in such a r e a s t h a t such an a r r a n g e m e n t is a g a i n s t the public interest. Some of the c o m m o n results a r e set out in the article by a school medical officer which will a p p e a r in our n e x t issue. In any case, it m u s t be clear to the M i n i s t r y t h a t the position is dangerous and t h a t alteration is u r g e n t l y necessary in the public interest when a prog r e s s i v e education c o m m i t t e e like that of B r a d f o r d joins with the local health c o m m i t t e e in a p p e a l i n g to the M i n i s t r y for an a u t h o r i t y to t r a n s f e r the whole of t h e medical .work to the local health c o m m i t t e e . B r a d f o r d : s case will als:o be published in our n e x t ~?~sue. So long as Sir G e o r g e N e w m a n was established at the B o a r d in a p o s i t i o N of c o n s i d e r a b l e a u t h o r i t y the school medical service was b e i n g continually g u i d e d t o w a r d s a co-ordination and coalescence with the g e n e r a l public health service, but since his r e m o v a l to the M i n i s t r y there have developed g r a v e l y ominous signs t h a t the powers at the Board have joined forces with t h e r e a c t i o n a r y local elements in order to set the current in the opposite direction and to constitute the w o r k r e l a t i n g to the health of school children as a minor departmerit in t h e office of the director

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PUBLIC

of education. If t h i s t e n d e n c y is allowed to develop, o r even continue, it xgitl be necessary For the Society of Medical Officers of H e a l t h 'to t a k e the e x t r e m e steps in order to w a r n the public of its d a n g e r , as every health officer is entirely of the opinion of Sir G e o r g e N e w m a n , which is e x p r e s s e d so clearly in his a d m i r a b l e r e p o r t for 19'20, in which he refers to the dependency of success in health w o r k in schools upon ante-school and post-school activities, and u r g e s the i m p o r t a n c e of co-relation and co-ordinati0n. Effective co-relation and coo r d i n a t i o n can only be secured by unity of command, centrally and locally. in some a r e a s the tack of co-relation and coo r d i n a t i o n is not only directly d i s a d v a n t a g e o u s to the d e v e l o p m e n t of the w o r k and to the public service, but has led to an intolerable posi'tic~n. T h e fact t h a t this service is mis-labetled " educat i o n , " combined with the fact t h a t g r a n t s in aid thereof are p a i d as p a r t of the g e n e r a l " education " g r a n t has led some education c o m m i t t e e s to r e g a r d it as one of the m i n o r educational services to be controlled entirely by the director of education. In such a r e a s the whole service is s e e t h i n g with discontent, which n m s t inevitably reflect upon the q u a l i t y of the w o r k , and the w o r k itself is carried out w i t h o u t a n y relationship to 0tl~er public health activities in the district, and in some cases in a c t u a l c o m p e t i t i o n with them. The p r e s e n t position is one which would not be p e r m i t t e d to continue in any b i g business o r g a n i s a t i o n , and we feel confident t h a t the m a t t e r has only to be p u t clearly before the p r e s e n t M i n i s t e r for him to d e t e r m i n e t h a t the time has a r r i v e d when the clear intentions of P a r l i a m e n t in p a s s i n g the M i n i s t r y of HeAlth Act m u s t be carried out, and t h a t the whole of t h e medical woek of the B o a r d of Education should now_be t r a n s f e r r e d to the M i n i s t r y o f H e a i t h , and t h a t " i h e ' p o s i t i o n locally should be est~ib]ished legally "by' the very small a m o u n t of legislation t h a t would be n e c e s s a r y in o r d e r to c o m p l e t e the trangfer locally as well as c61{trally. Thh actu'al legislation n e c e s s a r y will, of course, be decided by the legal adviserS' to the M i n i s t r y , but it m a y be. s u g g e s t e d t h a t a v e r y simple . a m e n d m e n t of Section g. of the E d u c a t i o n Act, 192J, would suffice. If Section 4- (2) (a) could have inserted in .it tlie w o r d s " except-.as r e g a r d s the medical inspection and t r e a t m e n t of school children," rite position would a p p a r e n t l y be m a d e satisfactory, as this w o r k would then fall n a t u r a l l y upon the Public H e a l t h C o m m i t t e e of the local authority.

HEALTH

55 " THE TIMES."

The " Medical Cora-espondent " of " The T i m e s , " in his recent 'commm}lcations upon public medical m a t t e r s , resembles a spoiled child who d e s t r o y s in t u r n all his toys and is pleased with nothing. H e criticises v e n o m o u s l y iatl public medical services and shows incidentally a v a s t i g n o r a n c e a b o u t them, and at the s a m e time he can see n o t h i n g b u t evil in medical w o r k under the I n s u r a n c e A c t - - a system which und o u b t e d l y c o n t a i n s the g e r m s of t h e only practica b l e s y s t e m of a public medical service w o r k e d by medical p r a c t i t i o n e r s w h o are not whole-time officers of the State. A p p a r e n t l y the only w a y to p l e a s e him w o u l d be to return to the g o o d old d a y s when the p r a c t i t i o n e r was given i n s u r a n c e w o r k b y F r i e n d l y Societies, as a g r e a t favour, a t a b o u t four shillings per head p e r annum. W e believe t h a t the w r i t i n g s of this g e n t l e m a n a r e being a s s e s s e d at their real vaIue .by the public, but there is a real possibility t h a t h e . m a y succeed in c r e a t i n g ill-feeling between the p r i v a t e p r a c t i t i o n e r a n d the medical officer: unless the B . M . A . t a k e s special steps to p r e v e n t it.

\,VILLESDEN B.M.A. DIVISION. " The T i m e s " has w o r k e d itself up into some e x c i t e m e n t over an alleged p r o p o s a l of the YVillesden D i v i s i o n of tim British Medical A s s o c i a t i o n to combine with the W i l l e s d e n R a t e p a y e r s ' A s s o c i a t i o n in an a t t a c k upon the medicat officer of health, and it has a s c r i b e d the a b a n d o n m e n t of the p r o p o s e d m e e t i n g to the influence of the Society of M e d i c a l Officers of H e a l t h . This is of c o u r s e entirely wrong, but it serves the p u r p o s e of the Times, w h i c h is to c r e a t e as much b a d blood as" possible between t i l e ; public health &ervice and g e n e r a l p r a c t i t i o n e r s . T h e Society of Medical Officers of H e a l t h has no influence at all which i t c o u t d cxercige in p e r s u a d i n g the YViltesden Division to a b a n d o n its e x t r a o r d i n a r y project. All t h a t the Society has done is to remind the S e c r e t a r y of the British Medical Association t h a t there is a subject k n o w n as " Medical E t h i c s , " and, a c t i n g on this reminder, the Secret a r y of the British Medical A s s o c i a t i o n has pres u m a b l y a d v i s e d the VVillesden Division as tc; the best course it could t a k e in the m a t t e r , and this advice has p r e s u m a b l y led to the a b a n d o n m e n t of the meeting. At the same time we r e g r e t that