Acceleration of medical planning

PUBLIC

HEALTH T H E JOURNAL OF

T H E SOCIETY OF MEDICAL OFFICERS OF H E A L T H No.

7.

APRIL, 1943

Vol. LVI. GONTENTS PAGE

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Nurses'

Salaries

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Health

and Vitamins

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OBITUARY 77 80 83

BOOK REVIEW Food,

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NEWS AND SUMMARIES Recruitment of Public Health Officers . . . ...... . Recent Appointments in the Public Health Service

SPECIAL ARTICLES Social Health and Social Happiness. B y H . P . N e w s h o h n e , M.D., V.mC.P., D,V,H . . . .. . . . -.. . . . . . . . Social Medicine. 'By W . " G . B o o t h , tvi:h., D.'I':tt . . . . ... Proposed Supplementary Register of Tuberculosis-Traine£( Nurses. l}y H . G . T r a y e r , M,B., mCH., D.P.H . . . . . . . . . . . . . . . .

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CORRESPONDENCE

EDITORIAL Ac
84

EDITORIAL Acceleration of Medical Planning The medical prof~:,sion is perhaps more interested Jn the Beveridge Report than any other section of the community, and since the publication of our last issue considerable developments in connection with it have taken place. I n the first place the Report has been fully debated in both Houses of Parliament, and the general outcome of this is a feeling among many people that the Government's acceptance of the Report as a whole has been rather lukewarm, and that Social Security will have to take its chance among the financial priorities after the war. Perhaps the chief point of criticism has been the Government's refusal either to appoint a Minister or to establish a Ministry of Social Security forthwith. It is proposed instead that a nucleus staff should be set up now to work with the departments concerned to bring the project as a whole into legislative form. This staff would be responsible to the Minister without Portfolio, described by Lord Samuel in the Lords Debate with not undeserved sarcasm as " the Minister with Pigeon-holes." Outlining the Government's case in the House of Commons, Sir John_Anderson said that it was a question whether the unified organisation which the Government agreed was necessaw for the administration of the insurance side of the Social Security scheme should be some kind of statutory board or a new Ministry. Ministry or Board, it is not to be set up until legislation introducing the new scheme has been passed in Parliament. The Government has accepted Sir Wittiam's three assumptions, and Sir J o h n Anderson made it clear that it regarded the scheme as a single, coherent plan of social insurance. It has, nevertheless, not yet accepted Sir William's proposals on woikmen's compensation, and it has not agreed that insurance benefit should be on a subsistence basis. Sir Kingsley Wood's speech hinted that financial obstacles to the fulfilment of the Beveridge plan might be formidable. As to Sir Wiltiam's Assumption B, Government spokesmen in both Houses stated unequivocally that the Government had " every intention of carrying out the comprehensive health service." This, Sir John observed, implied the reorganisation of the existing services--National Health Insurance, the general and specialist health services of local authorities, major hospital and institutional services, and so on. The object was to secure, through a public organised and regulated service, that every man, woman and child who wanted it could obtain the whole range of medical advie~e and attention, tie advocated the fullest co-operation public authorities and voluntary agencies. A p p a r e n t l y / ~ e

Dr. G. B. Dixon Dr. T. Holt

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THE SOCIETY OF MEDICAL OFFICERS OF HEALTH General Purposes Committee . . Northern Branch . . . . . . . . . Yorkshire Branch . . . . . . . . . Midland Branch . . . . . . . . .

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responsibility for seeing that the service in any area was complete was to be laid upon public authorities. T h e Government has declared its intention not to proscribe private practice, not to destroy the institution of voluntary hospitals, not to compel any person to participate in it, and not to make medical practitioners serve obligatorily. Correspondence in the medical Press suggests that doctors on the whole welcome the general trend of the Beveridge Report, and especially its attack upon w a n t ' a n d idleness. A considerable section, however, fear that the Government wishes to use the Beveridge Report as an opportunity to establish a whole-time State-salaried service--a project which has received the official support of the Society of Medical Officers of Health. The Council of the B.M.A. is recommending to its Representative Body that it should co-operate with the Government in the preparation of a comprehensive health and rehabilitation service, provided (1) that the Government accepts the Assumptions of the Report and decides to put into operation the proposals of the Report taken as a whole ; (2) that the character, terms, and conditions of the medical service are determined by negotiation and agreement with the medical profession, and (3) that persons should be able to obtain their medical service privately from doctors within the scheme if they so wish. I n other words, the B.M.A. wishes to preserve the right of doctors to make private arrangements with approximately 10% of the-population. The disadvantage of this is that it leads to the suggestion that there will be two kinds of medical service, one kind for those within the insurance scheme, and another kind for those who are prepared to pay a little bit more. As in all such matters in this country, the question will be decided by the people themselves, and if, as is very probable, the more well-to-do section of the community wish to make their private arrangements in the same way as they wish to arrange for the private education of their children, then it is unlikely that the Government would introduce any legislation preventing this. There is a danger, however, that the scheme may split the profession into two groups, one engaged entirely in private and one in public service. Quite apart from motives of self-interest, there are also many medical men who view with abhorrence a complete regimentation of a profession which in a non-regimented scheme has made considerable contributions to human knowledge and culture. The Government has been quick off the mark in making arrangements for discussions on the comprehensive medical service, and a number of deputations have already at the M i n i s t w of Health to hear the Government's ry observations. On March 9th representatives of

76

PUBLIC HEALTH, April, 1943

the Society of Medical Officers of Health, of the B.M.A., and the authorities expected a considerable number to practise the Royal Colleges, heard what the Minister had to say about fornication. The root of the trouble was the treatment of the discussions which will take place during the coming what was primarily a moral problem as if it were primarily a months. The outcome of this is the statement by the Secretary medical problem. After setting forth seven points for conof the B.M.A., published in the British Medical ~tournal of sideration in any educational campaign, the Archbishop conMarch 20th. No further indication is yet given of what the cluded, " Let all our handling of this topic express the conGovernment's proposals for reorganisation of the medical viction that fornification, be it rare or common, is something services are to be. The two important features of the B.M.A. that arouses the condemnation of all decent citizens and ' the Secretary's statement are (1) a letter from Sir John Maude, dreadful a~tonishment of God.' " Among the many speakers, Dr. Otto May agreed that the Secretary to the Ministry, and (2) the publication of a list of men prepared to serve on a committee to represent the pro- medical part of the problem was subsidiary. He thought fession in the discussions with the Ministry. At a time when there was a great deal of exaggeration in the talk about a primidisunity in the profession would be disastrous, it is a good tive urge. Dr. Maitland Radford said that the difference omen that the Royal Colleges have agreed to sit round a between the secular and the religious approach did not concommon table with such professional organisations as our stitute a barrier. His Grace had said that it should be part own and the B.M.A. It will be agreed that in its opening of the education campaign to teach the sacredness of sex, but moves the Ministry has shown considerable wisdom and a desire it was untrue to represent it as a fact that sex was universally to treat the medical profession in an open manner. The doctors regarded as being sacred. The secular approach to sex allowed of the country have been granted a considerable conces- a wider latitude/-n sex behaviour than did the religious approach. Dr. T. O. Garland complained that pamphlets on health educasion in that the Government, as it made clear in Sir John Maude's letter, will not put before Parliament proposals tion, while mentioning venereal diseases, did not mention the for legislation on a comprehensive medical service until the symptoms by which they could be recognised nor did they general lines of such proposals have been placed before the give information on prophylaxis. Perhaps it is well to be clear about one or two things. From medical profession, so that it may have an opportunity for discussion and representation. Sir John also observes that the point of view of the churchman, extramarital intercourse the Government, in framing a time-table, will not forget that or sexual promiscuity is sinful. It is a moral problem. But the many medical men are serving overseas. The B.M.A. has contraction of venereal disease and the treatment of it constitute undertaken to circularise the Government's proposals to all a medical problem. ~ I n the prevention of venereal disease Service men when the time comes. This is a critical moment there are both a medical and a moral problem. Those who for the medical profession, and any Government scheme is adopt the religious attitude to sexual promiscuity must naturbound to disappoint large sections of the profession. No ally preach against fornication as an evil thing. Those who doubt the English virtue of compromise will strike a mean do not have this religious abhorrence of fornication--and this between extreme doctrinaire viewpoints and the stubborn probably includes many medical men--will wish to try to facts of human nature that are plainly manifest in daily practice. prevent venereal disease by applying measures based upon The price to be paid for unification of medical services must their kn~)wledge of the spread of infection. I n a general discussion of the sexual problem it is a pity that the psychologist not be uniformity of medical men. and the physiologist did not put in a word. The physiologist might well hold that, just as it is impossible without harming Conference on V.D. Under the chairmanship of Dr. Charles Hill, the Central the organism to interfere with the physiological mechanism Council for Health Education convened in February a con- of digestion, so is it not possible without harm to interfere ference to discuss the education ,campaign against venereal with the probably far more elaborate physiological mechanism diseases. The meeting was well attended, and the level of of sex. It would be interesting to know on exactly wha t debate high. It attracted widespread attention because of evidence propagandists base the statement that continence is the appearance on the platform of distinguished speakers, in- either harmful or not harmful. It would appear that medical cluding the Archbishop of Canterbury, whose active interest in and psychological studies have not progressed far enough to social matters generally is beginning to remove a criticism that justify dogmatism on these topics. grew between the two wars that the Established Church remains too cloistered from the common concerns of the people. Closure of Tuberculous Cavities The proceedings were opened by the Minister of Health, who I n spite of the improvement in the prospect for patients observed that Defence Regulation 33B, which was deliberately suffering from certain types of pulmonary tuberculosis which limited in scope, left unchanged the general voluntary basis of artificial pneumothorax, thoracoplasty and other surgical treatment. Dr. Temple said that he had thought of resigning procedures have brought about, there are still many for whom from his Presidency of the Central Council fo, Health Educa- they are inappropriate, Especially among those who have been tion so that he could be free to criticise Regulation 33B. But established, perhaps for generations, as dwellers in big towns, the Minister of Health had asked him to retain the office of slowly progressive bilateral disease is common and may be President while being free also to criticise the Regulation. He associated with cavitation ; and in some unilateral cases with wished, he continued, to press for a rapid extension of the cavitation patients are too ill for a major operation. These provision of clinics and for a great development of public patients are a discomfort to themselves and a danger to others propaganda. I n the latter he wanted the moral appeal to take because of the large volumes of sputum they discharge. Transthe foremost place. If men and women would abstain from pleuml drainage of cavities may give temporary relief but, as fornication, the problem confronting the Minister of Health Maxwell and Kohnstam* have shown, cannot Be relied upon would be reduced to negligible proportions. What was left to bring about their permanent closure so long as connection would be a purely medical problem. The bulk of the evil between cavities and bronchi persists. The solution of this was primarily a moral problem and should therefore be difficulty has been sought by Thomas, Gough and Stillt approached in the way most likely to produce the desired through artificial occlusion of the bronchial connection. They moral results. The first object to be aimed at was the practice ha~e found that when the bronchi draining chronic tuberculous of continence. I n a long-term policy it was plain that the cavities are blocked with plasma clot the cavities tend to coninfluence of a good home vastly exceeded any other. More tract and disappear. This was shown in patients on whom powerful than any teaching was the suggestion afforded by transpleural cavity drainage (Monaldi technique) had failed to habits of practice and conversation and by the attitude adopted produce closure of the cavities. Autogenous oxalated plasma by society. It was a fundamental principle that Governments was introduced into the cavities via the drainage tube, the affect the conduct of their subjects far more by the principles plasma being so treated beforehand that it clotted shortly after implicit in their acts than by the requirements of legislation entering the.cavity and the draining bronchi. or the severity of penalties. I n the Army instruction was given to recruits iri the use of prophylactics with a view to * Brit. y. Tuberc. ~ Dis. Chest, 1943, 37, 34. t Ibid., 1943, 37, 44. checking venereal disease. The implication of this was that