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Accidents in the home
118
PUBLIC HEALTH, ACCIDENTS
IN
THE
HOME *
By AMY JAGGER, M.D., D.P.H. Assistant County Medical Q~cer, Glarnorgan I t is t h e c u s t o m for P r e s i d e n t s of t h i s B r a n c h of the Society to give a n address at t h e first m e e t i n g at w h i c h t h e y preside. S o m e c a n describe i n t e r e s t i n g experiences t h e y have h a d or e x p e r i m e n t s they have carried out. I have h a d n o experiences in the field of m e d i c i n e w h i c h w o u l d i n t e r e s t you n o r have I a n y research to speak a b o u t ; b u t while I was t h i n k i n g of these things, I had a m i n o r road accident a n d m y m i n d b e i n g full of the two s u b j e c t s - - t h e accident a n d t h e P r e s i d e n t ' s a d d r e s s - - I decided t h e y s h o u l d b e c o m b i n e d and I w o u l d talk of accidents, n o t road accidents b u t accidents in t h e h o m e , w i t h special reference to t h e i r prevention. I t is a relief to c o n c e n t r a t e o n a small domestic p r o b l e m w h e n those of t h e world seem i n s o l u b l e a n d nations prepare for w a r while s t a t e s m e n travel hopefully f r o m c o u n t r y to c o u n t r y a n d talk of peace. Soon t h e y m a y fly faster t h a n s o u n d , t h e i r voices e c h o i n g emptily b e h i n d t h e m . A f t e r D u n k i r k a residential school for educationally s u b - n o r m a l girls was evacuated f r o m a city in t h e M i d l a n d s to a c a m p o n t h e edge of an a e r o d r o m e in G l a m o r g a n . I t was a h u t t e d c a m p a n d could have b e e n m i s t a k e n for a n a r m y c a m p even f r o m the g r o u n d . I was sent to refract t h e c h i l d r e n w i t h defective vision a n d p r e s c r i b e glasses for t h e m . T h e r e were f r e q u e n t air raid w a r n i n g s a n d we all had to r u n out a n d s t a n d u n d e r t h e h e d g e w h i c h d i d n o t p r o t e c t us f r o m t h e rain while G e r m a n planes p r e s u m a b l y flew overhead. I t s e e m e d a futile occupation. B u t because it a s s u m e d that t h e c h i l d r e n w o u l d live a n d t h a t the spectacles w o u l d be p r o v i d e d for t h e m , it was as good for t h e m o r a l e of all c o n c e r n e d as Sir W i n s t o n C h u r c h i l l ' s famous speech m a d e at t h e same time. I n t h e same way, w h e n at least half t h e world is terrified o f w h a t t h e n e w e s t weapons. of w a r m a y accomplish it will be good for us n o w to a s s u m e t h a t h o m e s will c o n t i n u e a n d t h a t accidents in t h e m can b e prevented. T h e r e are n o records of the actual n u m b e r of accidents in the h o m e o c c u r r i n g in a n y year in this country, or even of the n u m b e r of accidents treated i n hospital, b u t accidents are n o w t h e fifth cause of d e a t h a n d in c h i l d r e n b e t w e e n the ages of one a n d five years accidents in the h o m e a r e t h e t h i r d cause of death. F r o m 1940 to 1949 over 60,000 people died f r o m accidents i n t h e h o m e , c o m p a r e d w i t h 48,000 in road accidents I A n d h o m e is y o u r safe place I W i t h over 1,000 m o r e deaths f r o m accidents t h e r e every year t h a n i n t h e road. L o o k e d at economically, it has b e e n e s t i m a t e d t h a t in 1949 in one hospital serving a p o p u l a t i o n of 13,000 in a c o n g e s t e d u r b a n area the cost of t r e a t i n g accident cases was s T h e cost to t h e w h o l e c o u n t r y in hospital treatm e n t alone is a b o u t s to s p e r year. W i t h m o d e r n m e t h o d s of t r e a t m e n t m a n y seriously i n j u r e d n o w survive b u t often in s u c h a c o n d i t i o n t h a t they are u n a b l e [o earn t h e i r living. T h e r e are very accurate a n d detailed records of road accidents because of t h e i n s u r a n c e m o n e y involved. A c c i d e n t s in the h o m e do not usually raise p r o b l e m s of this k i n d a n d there are very rarely a n y legal actions or enquiries unless a c o r o n e r ' s i n q u e s t is needed. T h e slightest road accident is d r a m a t i c a ~ d causes a sensation in t h e street w h e r e it occurs, b u t people can b e very seriously i n j u r e d in t h e i r o w n h o m e s w i t h o u t a n y o n e except those in the h o u s e b e i n g aware of it. T h e age groups m o s t p r o n e to accidents in t h e h o m e are t h e v e r y y o u n g a n d those over 60 years old. T h e greatest n u m b e r of fatal injuries are due to people falling d o w n : it is i n t e r e s t i n g to note t h a t m o r e falls occur " o n t h e s a m e level " t h a n in going u p or d o w n stairs. A b o u t twice as m a n y w o m e n die f r o m this cause as m e n . F r a c t u r e d f e m u r s a n d Colles' fractures have always b e e n m o r e c o m m o n in w o m e n t h a n i n m e n . T h i s difference in 9 eresicientialActdr~ssto- tiae~c~Zels-hBranch, Society of" M.D-[H[
May, 1955
incidence may b e due partly to w o m e n ' s clothing, h i g h heels, heels c a t c h i n g in h e m s of skirts, a n d also to t h e fact t h a t w o m e n t e n d to' m o v e a b o u t t h e h o u s e m o r e t h a n m e n , often carrying trays. T o reduce t h e n u m b e r of falls it is necessary to m a k e people consider t h e i r h o m e s f r o m this angle. M o s t houses have a h a z a r d well k n o w n to t h e f a m i l y - - t h e y say " S o m e day s o m e b o d y will b r e a k t h e i r neck o n those stairs " or " T h e r e s h o u l d b e a l i g h t in t h a t c o r n e r " or " W h e n is s o m e b o d y going to fix t h a t c a r p e t ? " But it is n o t u n t i l the anticipated accident has h a p p e n e d that s o m e t h i n g is done. T h e same people w h o will advocate t h e removal of a b u i l d i n g to increase road safety will n e v e r t h i n k of m o v i n g a piece of f u r n i t u r e in t h e i r own h o m e to increase the safety of their family. T h e highly polished w o o d e n floor is a m e n a c e : H o s p i t a l s and clinics are often v e r y bad examples of this. I fell a n d fractured t h r e e m e t a c a r p a l s w h e n a resident. A midwife in one of m y clinics fell a n d f r a c t u r e d h e r femur. S h e h a d to retire p r e m a t u r e l y and after m a n y operations is a p e r m a n e n t cripple. E i g h t weeks ago a h e a l t h visitor fell on p o l i s h e d linoleum, while c a r r y i n g a child w i t h infantile paralysis ; in saving the child she was u n a b l e to help h e r s e l f a n d f r a c t u r e d her s u p e r i o r maxilla. F o r t h o s e w h o can afford it fitted carpets a n d r u b b e r floor covering in k i t c h e n a n d b a t h r o o m are t h e ideal "in h o m e s w h e r e t h e r e are elderly people. T h e soles of shoes of old people w h o n e v e r go o u t b e c o m e s m o o t h a n d polished a n d s h o u l d b e r o u g h e n e d regularly. T h e p r e s e n t t e n d e n c y to keep old people o n t h e i r feet increases t h e n u m b e r liable to accident. It is often a relief to those w h o have to look after paralysed old p e r s o n s w h e n t h e y n o longer get u p b u t are safe in bed. E v e r y year t h e r e are a b o u t 600 deaths in t h e h o m e f r o m b u r n s a n d scalds a n d 12,000 seriously injured. T h e cost of i n - p a t i e n t t r e a t m e n t alone is a b o u t s T h i s is n o t a n e w p r o b l e m . M r . B r o n t 6 h a d a great d r e a d of fire. I n 1844 h e w r o t e to t h e Leeds Mercury " I have b e e n at H a w o r t h for m o r e t h a n 20 years a n d d u r i n g t h a t long p e r i o d of time so far as I can r e m e m b e r I have p e r f o r m e d t h e funeral service over 90 to 100 c h i l d r e n w h o were b u r n t to d e a t h in c o n s e q u e n c e of their clothes h a v i n g taken fire a n d on e n q u i r y I have f o u n d t h a t t h e p o o r sufferers h a d b e e n clothed in either c o t t o n or l i n e n . " H e insisted o n all m e m b e r s of his family always w e a r i n g wool or silk clothing. " I n d e e d for anyone to wear a n y o t h e r fabric was almost to forfeit his respect " said Mrs. Gaskell. H e would n o t allow any curtains to b e h u n g in t h e parsonage. U n f o r t u n a t e l y in spite of his care all his six c h i l d r e n were to die of tuherculos.is. M r . Bront6's p r o b l e m would have b e e n m u c h greater today. F a b r i c s are rarely w h a t t h e y s e e m a n d s y n t h e t i c materials have replaced or b e e n b l e n d e d with the n a t u r a l fibres for various reasons. C o n t r a r y to general belief these s y n t h e t i c substances m a y b e inflammable, s o m e t i m e s very m u c h so. I have h e a r d of a fabric, very beautiful to look at, w h i c h b u r s t s into flame s p o n t a n e o u s l y . It is said to b e too expensive to m a k e materials fire p r o o f except in special cases. Very beautiful fabrics are m a d e of glass, indist i n g u i s h a b l e from silks a n d satins. T h e y will n o t catch fire a n d are used extensively o n the stage. T h e y are suitable for curtains p r o v i d e d t h a t w h e n they are w a s h e d they are treated like a sheet of glass, they c a n n o t b e folded or screwed u p as some of t h e glass fibres will break, m a k i n g a r o u g h m a r k on the material. Similarly t h e y are not suitable for c l o t h i n g as the edges will a b r a d e t h e skin. U p h o l s t e r e d f u r n i t u r e w h i c h will s m o u l d e r for a long time has b e e n a f r e q u e n t cause of fires. I n M r : B r o n t 6 ' s t i m e t h e agents p r o d u c i n g the fire were t h e candle, t h e paraffin l a m p or t h e o p e n fire. T h e y could o n l y p r o d u c e fires. N o w we have coal gas w h i c h can also poison, a n d electricity w h i c h can also shock. W e also have t h e cigarette. T h e r e h a v e b e e n e n o u g h tragedies recently tO r e m i n d us of t h e n e e d for e d u c a t i n g people in t h e use of these dangerous everyday t h i n g s a n d t h e p r e c a u t i o n s t h a t
PUBLIC HEALTH,
May, 1955
o u g h t to be taken in fitting a n d u s i n g the various appliances. T h e effect of the H e a t i n g A p p l i a n c e s (Fireguards) A c t 1952 will n o t b e felt for m a n y years, as it is o n l y o n n e w fires t h a t these guards have to b e fixed. T h e A c t o n l y c o n c e r n s gas a n d electric fires. T h e r e is n o c o m p u l s i o n to have a g u a r d i n f r o n t of a coal fire. I n a survey in w h i c h over 1,000 houses were visited, only 3 6 % w i t h c h i l d r e n u n d e r six were u s i n g a fireguard. O n l y 7 % of houses w i t h people over seventy h a d guards. A good fireguard m a y cost s M a n y local authorities have schemes for h i r i n g out g u a r d s for a small weekly s u m . M o r e care s h o u l d b e t a k e n in t h e r e c o n s t r u c t i o n of old houses. O f t e n a n e w fireplace is fitted a n d the space at the back filled w i t h any r u b b i s h , w h i c h m a y catch fire. A friend of m i n e noticed s m o k e c o m i n g f r o m the side of h e r fireplace one m i d - d a y . T h e r e h a d b e e n n o fire in t h e grate since t h e previous n i g h t . H e r b a b y slept in t h a t r o o m alone. T h e firemen f o u n d a large fire b e h i n d the grate w h e n they pulled it o u t a n d told h e r this was a c o m m o n occurrence. S o m e n e w houses b u i l t b y local authorities have a fire in the sitting r o o m w i t h t h e c h i m n e y g o i n g u p t h r o u g h the centre of t h e h o u s e so t h a t heat is n o t lost o n an outside wall. Care m u s t be t a k e n in c o n s t r u c t i n g this flue. [ k n o w of two such houses w h e r e b e d r o o m f u r n i t u r e has b e e n destroyed t h r o u g h fire s t a r t i n g in the chimney. All t h e n e i g h b o u r s n o w k n o w t h e risk a n d t h a t t h e y c a n n o t have large fires in t h e grate for long periods. T h e possibility of w o r n electric wires s t a r t i n g fires is well k n o w n b u t little heeded, a n d m a j o r electrical alterations are o f t e n e n t r u s t e d to amateurs. I was told of a certified m e n t a l defective t h a t h e was marvellous w i t h electricity a n d d i d all t h e n e i g h b o u r s ' electrical repairs. M a n y scalds are due to p a n s b e i n g k n o c k e d off t h e t o p o f gas stoves. I f all t h e b u r n e r s are in use at t h e same time, as in cooking a family d i n n e r , t h e p a n h a n d l e s m u s t project b e y o n d the edge of t h e gas stove. I f they do n o t t h e y get very hot. I n D e n m a r k t h e y appear n o t to use gas cookers such as we have here : t h e y have a m e t a l - t o p p e d t a b l e with a n u m b e r of m o v a b l e gas rings o n it, w h i c h can b e a d j u s t e d so t h a t t h e r e is p l e n t y of space b e t w e e n t h e p a n s a n d t h e r e is r o o m to s t a n d the p a n s o n the table w h e n t h e y are t a k e n off the rings. T h e oven is a separate box at table height. T h e a r r a n g e m e n t takes u p m o r e r o o m a n d js n o t so nice to look at as o u r gas cooker b u t it is easier a n d safer to work with. T h e r e is n o d a n g e r of p a n s b e i n g knocked over so t h a t t h e i r c o n t e n t s are spilled over a n y o n e s t a n d i n g near. H o t w a t e r appliances s h o u l d b e regulated so t h a t t h e y c a n n o t p r o d u c e water t h a t will scald. W h e n one considers t h e difficulty of cooking-on.,an o r d i n a r y sitting r o o m grate b y the m o t h e r of a family living in o n e or two rooms, o n e is n o t s u r p r i s e d t h a t fish a n d chips a n d food f r o m tins f o r m t h e s t a n d a r d meals. It is t e m p t i n g P r o v i d e n c e to heat p a n s a n d kettles on such a grate w i t h small c h i l d r e n about. I t requires a very clever p e r s o n to m a n a g e u n d e r s u c h conditions b u t usually it is t h e duller ones w h o have to do so, I n schools usually t h e m o s t expensive m o d e r n fittings are p u t into t h e rooms w h e r e girls learn housework. I t is easy to learn to use these. It w o u l d b e b e t t e r to c o n c e n trate o n t e a c h i n g t h e m h o w to m a n a g e w i t h the m i n i m u m a n d to improvise a n d work in c o n d i t i o n s w h i c h t h e y m a y have in t h e i r o w n homes. Between 400 a n d 500 p e r s o n s die each year f r o m accidental p o i s o n i n g w i t h coal gas, m o s t of t h e m in t h e i r o w n h o m e s a n d t w o - t h i r d s of t h e m over 60 years of age. T h e chief causes are partly t u r n e d off gas taps, so t h a t t h e flame goes out, poor ventilation, blocked flues a n d w o r n out a p p a ratus. T h e d a n g e r of u s i n g a gas fire w i t h o u t adequate v e n t i lation is often n o t appreciated. M a n y rooms are n o w b u i l t w i t h o u t fireplaces a n d the occupants f r e q u e n t l y block t h e wall ventilator. Gas fires s h o u l d n o t be u s e d in s u c h rooms. Last w i n t e r two w o m e n a n d four c h i l d r e n were f o u n d u n c o n s c i o u s a n d only two recovered. T h e y were in a r o o m w h e r e t h e c u r t a i n s h a d b e e n d r a w n a n d the gas fire p u t o n the m a n t e l p i e c e out of t h e way of the children.
119 G a s taps s h o u l d n o t be so loose they can be t u r n e d o n inadvertently. Gas a n d electricity authorities will s e n d an i n s p e c t o r to test t h e appliances in any house o n request, b u t those w h o are m o s t d o u b t f u l a b o u t t h e i r e q u i p m e n t will n o t ask for this to be done as t h e y are fearful of the expense that m a y be i n c u r r e d as a result. D r u g s cause t h e next greatest n u m b e r of deaths f r o m p o i s o n i n g a n d most, if n o t all, accidents of this k i n d could be avoided if medicine, cleaning materials a n d o t h e r d a n g e r o u s substances were kept in a safe place w h e r e c h i l d r e n could n o t get t h e m a n d adults would have to b e wide awake and alert to get t h e m . So m a n y children have b e e n p o i s o n e d b y eating tablets such as those c o n t a i n i n g ferrous s u l p h a t e t h a t it was considered recently that m e d i c i n e s h o u l d n o t be dispensed in this form, so easily m i s t a k e n by c h i l d r e n for sweets. B u t the p u b l i c has got used to its s u g a r - c o a t e d pill. G o n e are t h e days of the doctor's " g o o d bottle of m e d i c i n e " a p p a r e n t l y m i x e d b y his o w n h a n d w i t h t h a t little extra a d d e d for " t h e pain in m y back " or " this c o u g h . " I t has b e e n succeeded b y t h e t a b l e t f r o m the c h e m i s t often d e m a n d e d b y t h e patient. T h e bottle of m e d i c i n e could be s h o w n to the family a n d visitors, held u p to t h e light, shaken, s m e l t a n d even tasted and everyone could guess its composition. S o m e older people still pathetically e x h i b i t t h e i r tablets b u t t h e y vary little in appearance a n d n o t h i n g interesting can b e d o n e w i t h t h e m except c o u n t t h e m . I t h i n k doctors have t h r o w n away a very valuable w e a p o n in t h e psychological t r e a t m e n t of t h e i r p a t i e n t s and it is p e r h a p s significant t h a t h o m e o p a t h y is increasing. H o w e v e r , we m i g h t as well t r y to stop road accidents b y s t o p p i n g all traffic as stop p o i s o n i n g accidents b y t r y i n g to b a n t h e s e tablets. W h a t m u s t b e d o n e is make people aware of t h e d a n g e r a n d t h a t t h e y m u s t protect t h e i r c h i l d r e n f r o m it. T h e d e a t h of a h e a l t h y n o r m a l child is a whole life t h r o w n away. " C u t is the b r a n c h that m i g h t have g r o w n full s t r a i g h t . " I n all p r o p a g a n d a work we m u s t r e m e m b e r t h a t we live in an age of exaggeration. T h e ear is t u n e d to t h e l o u d speaker, the eye to see in gorgeous T e c h n i c o l o r , n o t i m e can b e spared to s t u d y details, a n d people b o a s t of t h e n u m b e r of t h i n g s t h e y can do at t h e same time. T h e r e f o r e , it is n o use h a n g i n g u p a notice or giving people a leaflet a n d expecting t h e m to read it. T h e r e m u s t b e a poster w i t h an appropriate picture a n d a few simple w o r d s s u c h as " Y o u r m e d i c i n e b u t his Poison. K e e p medicines locked u p . " I t occurs to m e t h a t d r u g a n d b a b y food m a n u f a c t u r e r s , w h o u n d e r s t a n d so well the art of advertising, m i g h t be p e r s u a d e d to take part. T h e y could c o m b i n e it w i t h an a d v e r t i s e m e n t s u c h as " T a k e A & B for your h e a d a c h e b u t d o n ' t let b a b y have it " or " Feed your b a b y o n X food b u t lock y o u r medicines away." Accidental s m o t h e r i n g in b e d or cot is m o r e likely to h a p p e n to a b o y t h a n a girl baby. N o reason has b e e n a d v a n c e d for this. It is always claimed t h a t w o m e n have m o r e highly developed instincts a n d intuitions t h a n m e n a n d rely on these r a t h e r t h a n r e a s o n i n g power, w h i c h t h e y are said to lack. P e r h a p s this i n s t i n c t tells t h e b a b y girl she is s m o t h e r i n g a n d induces her to t u r n over. A n o t h e r " M i s t l e t o e " B o u g h accident is h a p p e n i n g in America w h e r e in 12 m o n t h s 85 c h i l d r e n have died t h r o u g h h i d i n g in a b a n d o n e d ice boxes a n d b e i n g u n a b l e to get out. T w o bills are n o w before Congress m a k i n g it illegal to s u p p l y any ice box or refrigerator " u n l e s s it is e q u i p p e d w i t h a l a t c h w h i c h enables it to be o p e n e d f r o m t h e i n s i d e . " T w e n t y States have m a d e it illegal to " a b a n d o n a n ice box w i t h o u t first r e m o v i n g the d o o r or l a t c h . " P e r h a p s we shall n e v e r reach the stage of t h r o w i n g away ice boxes in this c o u n t r y b u t i t is as well to b e f o r e w a r n e d of t h e danger. W h i l e I have b e e n s u m m a r i s i n g the m a i n types of h o m e accident a n d t h e i r causes you will have t h o u g h t of m a n y more. P r e v e n t i v e m e d i d i n e has b e c o m e increasingly d i r e c t e d to i m p r o v i n g t h e resistance to disease r a t h e r t h a n r e m o v i n g t h e causes, a n d m e d i c a l officers a n d h e a l t h visitors devote m o r e a n d m o r e of t h e i r time to i m m u n i s i n g and vaccinating.
P U B L I C H E A L T H , M a y , 1955
120 T h e n u m b e r of cards a n d f o r m s t h e h e a l t h visitor has to fill in a n d i n d e x leaves h e r little time for t h e w o r k for w h i c h she has b e e n t r a i n e d - - e . g , itTis necessary for t h e n a m e a n d address of a n e x p e c t a n t m o t h e r to b e w t i t t e n o u t n i n e t i m e s t h e first time she attends t h e clinic if she wishes to take a d v a n t a g e of all the facilities available 9 T h e liability to have a n accident m a y be decreased b y s u c h t h i n g s as w e a r i n g correct spectacles, h e a r i n g aid, u s i n g w a l k i n g stick a n d wearing cbrrect shoes b u t t h e p u b l i c m u s t also b e e d u c a t e d so t h a t they k n o w t h e causes of accidents a n d can recognise defects in t h e i r o w n h o m e s or h a b i t s a n d rectify t h e m themselves. T h i s is n o t easy work. As t h e G r e e k p h i l o s o p h e r Heraclitus said " t h o u g h reason is accessible to all, m o s t people, it seem.s, incline to live according to t h e i r o w n n o t i o n s . " Throughout nature the mother protects her young from d a n g e r a n d educates t h e m for life. T h e m o t h e r of t h e child will b e anxious to protect it f r o m accident if the n e e d is explained to her. T h i s is particularly t r u e of t h e expectant p r i m i p a r a w h o s e m i n d is i n a v e r y receptive state. S h e is anxious to prepare for the c o m i n g b a b y a n d has t i m e to plan h e r h o m e so t h a t it will b e suitable for t h e child w h e n it starts to walk. A f t e r t h e b a b y is b o r n its g r o w t h is so rapid that t h e m o t h e r is so occupied t h a t it m a y b e o n its feet a n d into t h e fire before t h e n e e d for a fireguard has b e e n realised. T h e m o t h e r could also c o n d i t i o n h e r s e l f to good h a b i t s so that, for example, s h e w o u l d n e v e r p o u r hot w a t e r into an e m p t y bowl. W o m e n ' s organisatioils are particularly i n t e r e s t e d in t h e p r e v e n t i o n of h o m e accidents a n d w o u l d welcome advice o n w h a t to d o ' b e f o r e t h e accident, for they are t h e people m o s t likely to have a n accident. T h e radio, television, newspapers, t h e c i n e m a a n d w o m e n ' s magazines c a n all play t h e i r p a r t , i n e d u c a t i n g t h e p u b l i c as t h e y o f t e n do n o w i n R o a d Safety C a m p a i g n s . H o m e Safety C o m m i t t e e s are increasing in n u m b e r s , s p o n s o r e d b y t h e Royal Society for t h e P r e v e n t i o n of Accidents. G e n e r a l practitioners a n d c o n s u l t a n t s show great i n t e r e s t in this subject a n d a w h o l e n u m b e r of t h e P r a c t i t i o n e r was recently d e v o t e d to A c c i d e n t P r e v e n t i o n . T h e B . M . A . in its e v i d e n c e to t h e W o r k i n g P a r t y of H e a l t h Visitors this year a d d e d to t h e subjects suggested as suitable for h e a l t h e d u c a t i o n " t h e i m p o r t a n c e of e d u c a t i o n in accident p r e v e n t i o n , w i t h special reference to accidents in t h e h o m e . " B u t p r e v e n t i o n of disease is o n e of t h e chief r e s p o n sibilities of t h e M e d i c a l Officer~-of H e a l t h a n d his staff. T h e a m b u l a n c e service, t h e h o m e n u r s e a n d the h o m e help m a y all b e n e e d e d for the t r e a t m e n t of a h o m e accident a n d it is therefore even to t h e advantage of a h e a l t h d e p a r t m e n t itself to r e d u c e t h e n u m b e r of these accidents. Since I qualified m a n y changes a n d i m p r o v e m e n t s in t h e general h e a l t h of t h e c o m m u n i t y have b e e n achieved w h i c h t h e n s e e m e d impossible a n d c o m p a r e d w i t h these t h e reduction of h o m e accidents s h o u l d b e relatively simple. W i l l i a m Harvey, said " Civilisation is s i m p l y a series of victories over n a t u r e " a n d so t h a t we m a y leave this p r o b l e m in its t r u e perspective I w o u l d r e m i n d you t h a t in 1,500 the expectation of life at b i r t h was 30 years a n d L e o n a r d o da V i n c i was r e g a r d e d as an old m a n w h e n h e died at the age of 69. T h e expectation of life at b i r t h n o w is 70 years. B u t J e r e m y T a y l o r ' s r e m a r k is still t r u e " T o preserve a m a n alive in t h e m i d s t of so m a n y chances a n d hostilities is as great a miracle as to create h i m . " REFERENCES
LANE, MARGARET. T h e Bront~ Story. Accidents in the H o m e - - R e p o r t of the Standing Inter-departmental Conmaittee on Accidents in the Home. H.M. Stationery Office 1953. Memorandum of Evidence to Working Party on Health Visitors. (1954). B r i t . M e d . ~ . S u p p l e m e n t , i, 268.~ SIMPSON, KEITH. T h e Danger of Accidental Carbon Monoxide Poisoning. (October 2nd, 1954). B r i t . M e & J , ii, 774. Report of Registrar General. Medical Statistics, 1952.
By
T H E EPIDEMIOLOGY OF H E A L T H * JOHN LANDOR, M.R.C.S., L.R.C.P., D.P.H., M e d i c a l Officer o / H e a l t h ,
Borough
o/Bexley
T h e use of t h e expression " epidemiology of h e a l t h " h a s still to be d e f e n d e d in t h i s c o u n t r y a l t h o u g h i t h a s g a i n e d a s o m e w h a t wider c u r r e n c y in t h e U . S . A . I first saw it used in I948 in a l e t t e r f r o m t h e late Professor J o h n R y l g who had, t h e n , r e c e n t l y r e t u r n e d f r o m a lecture t o u r in A m e r i c a u n d e r t h e auspices of t h e Rockefeller F o u n d a t i o n . T h e first r e a c t i o n t h a t t h i s i n v o k e d was one of surprise a n d some concern t h a t t h e word " epidemiology " s h o u l d be j u x t a p o s e d to " h e a l t h " a n d not, in t h e c u s t o m a r y m a n n e r , t o " d i s e a s e . " G r e a t e r f a m i l i a r i t y w i t h t h e idea, however, n o t o n l y r e m o v e d t h e s e misgivings b u t b r o u g h t , in t h e i r place, a feeling of e m a n c i p a t i o n as b y t h e r e m o v a l of a n intellectual s t r a i t - j a c k e t a n d of a cold a n d i n v i g o r a t ing wind blowing d o w n t h e corridors of t r a d i t i o n a l practice. T h e first difficulty is of a n e t y m o l o g i c a l n a t u r e . I n 1952, Prof. A. G. G a r d n e r , of Oxford, a n a u t h o r i t y on t h e m e a n ing of words, p r o t e s t e d a g a i n s t w h a t he called t h e " undoubted debauchery of a precise word 'epidemiology ' ~ h i c h is being inflated b y writers on social medicine and similar subjects to include the study of the frequency or incidence of diseases whether epidemic or not. The right and 9 . . obvious meaning of ' e p i d e m i o l o g y ' is given b y the Shorter Oxford Dictionary as ' t h e Study of epidemics' and of an ' epidemic ' as a disease prevalent among a people or a community at a special time a n d produced b y some special causes not generally present in t h e affected locality.' Therefore to speak of the epidemiology of coronary thrombosis, or of hare-lip or diabetes' or of any non-epidemic disease is a debasement of the currency of thought. I t is no use saying t h a t the word is being used in its wider sense. It has no wider sense." I f this o b j e c t i o n is valid, " t h e r e w o u l d b e a n even g r e a t e r o b j e c t i o n to t h e a p p l i c a t i o n of t h e word " epidemiology " to h e a l t h . Greenwood, on t h e o t h e r h a n d , h a s p o i n t e d o u t t h a t epidemiology suggests, b y its derivation "a science of s o m e t h i n g falling u p o n t h e people a l t h o u g h it c a m e t o m e a n t h e s t u d y of disease, a n y disease, as a m a s s p h e n o m e n o n . " T h i s c o n t r o v e r s y is, of course, m u c h m o r e t h a n a m a t t e r ' o f m e r e semantics. M a n y infectious diseases h a v e b e e n v i r t u a l l y abolished as a result of a knowledge of t h e i r e p i d e m i o l o g y a n d if, for instance, c o r o n a r y t h r o m b o s i s a n d c a n c e r could b e s h o w n to h a v e a n epidemiology of t h e i r own, t h e e m p h a s i s would, inevitably, shift from cure t o p r e v e n t i o n . Similarly, if h e a l t h could b e s h o w n t o h a v e a n e p i d e m i o l o g y t h e e m p h a s i s would shift still f u r t h e r in t h e d i r e c t i o n of p r o m o t i o n . However, t o s u p p o r t s u c h a t h e s i s i t would b e n e c e s s a r y to show t h a t h e a l t h can, in fact, descend on a c o m m u n i t y p e r h a p s b y t h e a p p l i c a t i o n of a s y s t e m of social h y g i e n e w h i c h t h e late Professor R e n e S a n d defined as " t h e integ r a t i o n of m e d i c a l a c t i o n w i t h a collective c o m m u n a l discipline." Before t h i s c a n be done, however, c e r t a i n epidemiological similarities a n d differences b e t w e e n h e a l t h a n d disease m u s t be considered. T h e p h e n o m e n a of h e a l t h a n d disease h a v e this in comm o n : t h a t t h e y are b o t h links in a n epictemiological c h a i n of e v e n t s w h i c h m a y go b a c k days, or m o n t h s , or years. To t a k e specific instances, we k n o w little of t h e precursors of influenza or t h e reasons for t h e periodic recurrence of epidemics. I t is g e n e r a l l y held t h a t c o n t r i b u t o r y causes m a y b e meteorological changes, t h e a c c u m u l a t i o n of a large reservoir of susceptible persons, t h e presence of a n approp r i a t e s t r a i n of v i r u s w i t h , possibly, a n e x a l t a t i o n of virulence. I t is possible, therefore, t h a t w h a t seems to b e t b e s u d d e n descent of influenza on a p o p u l a t i o n is t h e r e s u l t of t h e i n t e r a c t i o n of m a n y f a c t o ~ w h i c h are in t h e m s e l v e s r e l a t i v e l y slow moving 9 Similarly t h e explosive n a t u r e of a n o u t b r e a k of w a t e r - b o r n e t y p h o i d fever m a y disguise t h e fact t h a t t h e w a t e r s u p p l y m a y h a v e b e e n sewage p o l l u t e d *Paper read to the Metropolitan Branch, Society of M.O.H., March I l t h , 1955.
PUBLIC HEALTH, ACCIDENTS
IN
THE
HOME *
By AMY JAGGER, M.D., D.P.H. Assistant County Medical Q~cer, Glarnorgan I t is t h e c u s t o m for P r e s i d e n t s of t h i s B r a n c h of the Society to give a n address at t h e first m e e t i n g at w h i c h t h e y preside. S o m e c a n describe i n t e r e s t i n g experiences t h e y have h a d or e x p e r i m e n t s they have carried out. I have h a d n o experiences in the field of m e d i c i n e w h i c h w o u l d i n t e r e s t you n o r have I a n y research to speak a b o u t ; b u t while I was t h i n k i n g of these things, I had a m i n o r road accident a n d m y m i n d b e i n g full of the two s u b j e c t s - - t h e accident a n d t h e P r e s i d e n t ' s a d d r e s s - - I decided t h e y s h o u l d b e c o m b i n e d and I w o u l d talk of accidents, n o t road accidents b u t accidents in t h e h o m e , w i t h special reference to t h e i r prevention. I t is a relief to c o n c e n t r a t e o n a small domestic p r o b l e m w h e n those of t h e world seem i n s o l u b l e a n d nations prepare for w a r while s t a t e s m e n travel hopefully f r o m c o u n t r y to c o u n t r y a n d talk of peace. Soon t h e y m a y fly faster t h a n s o u n d , t h e i r voices e c h o i n g emptily b e h i n d t h e m . A f t e r D u n k i r k a residential school for educationally s u b - n o r m a l girls was evacuated f r o m a city in t h e M i d l a n d s to a c a m p o n t h e edge of an a e r o d r o m e in G l a m o r g a n . I t was a h u t t e d c a m p a n d could have b e e n m i s t a k e n for a n a r m y c a m p even f r o m the g r o u n d . I was sent to refract t h e c h i l d r e n w i t h defective vision a n d p r e s c r i b e glasses for t h e m . T h e r e were f r e q u e n t air raid w a r n i n g s a n d we all had to r u n out a n d s t a n d u n d e r t h e h e d g e w h i c h d i d n o t p r o t e c t us f r o m t h e rain while G e r m a n planes p r e s u m a b l y flew overhead. I t s e e m e d a futile occupation. B u t because it a s s u m e d that t h e c h i l d r e n w o u l d live a n d t h a t the spectacles w o u l d be p r o v i d e d for t h e m , it was as good for t h e m o r a l e of all c o n c e r n e d as Sir W i n s t o n C h u r c h i l l ' s famous speech m a d e at t h e same time. I n t h e same way, w h e n at least half t h e world is terrified o f w h a t t h e n e w e s t weapons. of w a r m a y accomplish it will be good for us n o w to a s s u m e t h a t h o m e s will c o n t i n u e a n d t h a t accidents in t h e m can b e prevented. T h e r e are n o records of the actual n u m b e r of accidents in the h o m e o c c u r r i n g in a n y year in this country, or even of the n u m b e r of accidents treated i n hospital, b u t accidents are n o w t h e fifth cause of d e a t h a n d in c h i l d r e n b e t w e e n the ages of one a n d five years accidents in the h o m e a r e t h e t h i r d cause of death. F r o m 1940 to 1949 over 60,000 people died f r o m accidents i n t h e h o m e , c o m p a r e d w i t h 48,000 in road accidents I A n d h o m e is y o u r safe place I W i t h over 1,000 m o r e deaths f r o m accidents t h e r e every year t h a n i n t h e road. L o o k e d at economically, it has b e e n e s t i m a t e d t h a t in 1949 in one hospital serving a p o p u l a t i o n of 13,000 in a c o n g e s t e d u r b a n area the cost of t r e a t i n g accident cases was s T h e cost to t h e w h o l e c o u n t r y in hospital treatm e n t alone is a b o u t s to s p e r year. W i t h m o d e r n m e t h o d s of t r e a t m e n t m a n y seriously i n j u r e d n o w survive b u t often in s u c h a c o n d i t i o n t h a t they are u n a b l e [o earn t h e i r living. T h e r e are very accurate a n d detailed records of road accidents because of t h e i n s u r a n c e m o n e y involved. A c c i d e n t s in the h o m e do not usually raise p r o b l e m s of this k i n d a n d there are very rarely a n y legal actions or enquiries unless a c o r o n e r ' s i n q u e s t is needed. T h e slightest road accident is d r a m a t i c a ~ d causes a sensation in t h e street w h e r e it occurs, b u t people can b e very seriously i n j u r e d in t h e i r o w n h o m e s w i t h o u t a n y o n e except those in the h o u s e b e i n g aware of it. T h e age groups m o s t p r o n e to accidents in t h e h o m e are t h e v e r y y o u n g a n d those over 60 years old. T h e greatest n u m b e r of fatal injuries are due to people falling d o w n : it is i n t e r e s t i n g to note t h a t m o r e falls occur " o n t h e s a m e level " t h a n in going u p or d o w n stairs. A b o u t twice as m a n y w o m e n die f r o m this cause as m e n . F r a c t u r e d f e m u r s a n d Colles' fractures have always b e e n m o r e c o m m o n in w o m e n t h a n i n m e n . T h i s difference in 9 eresicientialActdr~ssto- tiae~c~Zels-hBranch, Society of" M.D-[H[
May, 1955
incidence may b e due partly to w o m e n ' s clothing, h i g h heels, heels c a t c h i n g in h e m s of skirts, a n d also to t h e fact t h a t w o m e n t e n d to' m o v e a b o u t t h e h o u s e m o r e t h a n m e n , often carrying trays. T o reduce t h e n u m b e r of falls it is necessary to m a k e people consider t h e i r h o m e s f r o m this angle. M o s t houses have a h a z a r d well k n o w n to t h e f a m i l y - - t h e y say " S o m e day s o m e b o d y will b r e a k t h e i r neck o n those stairs " or " T h e r e s h o u l d b e a l i g h t in t h a t c o r n e r " or " W h e n is s o m e b o d y going to fix t h a t c a r p e t ? " But it is n o t u n t i l the anticipated accident has h a p p e n e d that s o m e t h i n g is done. T h e same people w h o will advocate t h e removal of a b u i l d i n g to increase road safety will n e v e r t h i n k of m o v i n g a piece of f u r n i t u r e in t h e i r own h o m e to increase the safety of their family. T h e highly polished w o o d e n floor is a m e n a c e : H o s p i t a l s and clinics are often v e r y bad examples of this. I fell a n d fractured t h r e e m e t a c a r p a l s w h e n a resident. A midwife in one of m y clinics fell a n d f r a c t u r e d h e r femur. S h e h a d to retire p r e m a t u r e l y and after m a n y operations is a p e r m a n e n t cripple. E i g h t weeks ago a h e a l t h visitor fell on p o l i s h e d linoleum, while c a r r y i n g a child w i t h infantile paralysis ; in saving the child she was u n a b l e to help h e r s e l f a n d f r a c t u r e d her s u p e r i o r maxilla. F o r t h o s e w h o can afford it fitted carpets a n d r u b b e r floor covering in k i t c h e n a n d b a t h r o o m are t h e ideal "in h o m e s w h e r e t h e r e are elderly people. T h e soles of shoes of old people w h o n e v e r go o u t b e c o m e s m o o t h a n d polished a n d s h o u l d b e r o u g h e n e d regularly. T h e p r e s e n t t e n d e n c y to keep old people o n t h e i r feet increases t h e n u m b e r liable to accident. It is often a relief to those w h o have to look after paralysed old p e r s o n s w h e n t h e y n o longer get u p b u t are safe in bed. E v e r y year t h e r e are a b o u t 600 deaths in t h e h o m e f r o m b u r n s a n d scalds a n d 12,000 seriously injured. T h e cost of i n - p a t i e n t t r e a t m e n t alone is a b o u t s T h i s is n o t a n e w p r o b l e m . M r . B r o n t 6 h a d a great d r e a d of fire. I n 1844 h e w r o t e to t h e Leeds Mercury " I have b e e n at H a w o r t h for m o r e t h a n 20 years a n d d u r i n g t h a t long p e r i o d of time so far as I can r e m e m b e r I have p e r f o r m e d t h e funeral service over 90 to 100 c h i l d r e n w h o were b u r n t to d e a t h in c o n s e q u e n c e of their clothes h a v i n g taken fire a n d on e n q u i r y I have f o u n d t h a t t h e p o o r sufferers h a d b e e n clothed in either c o t t o n or l i n e n . " H e insisted o n all m e m b e r s of his family always w e a r i n g wool or silk clothing. " I n d e e d for anyone to wear a n y o t h e r fabric was almost to forfeit his respect " said Mrs. Gaskell. H e would n o t allow any curtains to b e h u n g in t h e parsonage. U n f o r t u n a t e l y in spite of his care all his six c h i l d r e n were to die of tuherculos.is. M r . Bront6's p r o b l e m would have b e e n m u c h greater today. F a b r i c s are rarely w h a t t h e y s e e m a n d s y n t h e t i c materials have replaced or b e e n b l e n d e d with the n a t u r a l fibres for various reasons. C o n t r a r y to general belief these s y n t h e t i c substances m a y b e inflammable, s o m e t i m e s very m u c h so. I have h e a r d of a fabric, very beautiful to look at, w h i c h b u r s t s into flame s p o n t a n e o u s l y . It is said to b e too expensive to m a k e materials fire p r o o f except in special cases. Very beautiful fabrics are m a d e of glass, indist i n g u i s h a b l e from silks a n d satins. T h e y will n o t catch fire a n d are used extensively o n the stage. T h e y are suitable for curtains p r o v i d e d t h a t w h e n they are w a s h e d they are treated like a sheet of glass, they c a n n o t b e folded or screwed u p as some of t h e glass fibres will break, m a k i n g a r o u g h m a r k on the material. Similarly t h e y are not suitable for c l o t h i n g as the edges will a b r a d e t h e skin. U p h o l s t e r e d f u r n i t u r e w h i c h will s m o u l d e r for a long time has b e e n a f r e q u e n t cause of fires. I n M r : B r o n t 6 ' s t i m e t h e agents p r o d u c i n g the fire were t h e candle, t h e paraffin l a m p or t h e o p e n fire. T h e y could o n l y p r o d u c e fires. N o w we have coal gas w h i c h can also poison, a n d electricity w h i c h can also shock. W e also have t h e cigarette. T h e r e h a v e b e e n e n o u g h tragedies recently tO r e m i n d us of t h e n e e d for e d u c a t i n g people in t h e use of these dangerous everyday t h i n g s a n d t h e p r e c a u t i o n s t h a t
PUBLIC HEALTH,
May, 1955
o u g h t to be taken in fitting a n d u s i n g the various appliances. T h e effect of the H e a t i n g A p p l i a n c e s (Fireguards) A c t 1952 will n o t b e felt for m a n y years, as it is o n l y o n n e w fires t h a t these guards have to b e fixed. T h e A c t o n l y c o n c e r n s gas a n d electric fires. T h e r e is n o c o m p u l s i o n to have a g u a r d i n f r o n t of a coal fire. I n a survey in w h i c h over 1,000 houses were visited, only 3 6 % w i t h c h i l d r e n u n d e r six were u s i n g a fireguard. O n l y 7 % of houses w i t h people over seventy h a d guards. A good fireguard m a y cost s M a n y local authorities have schemes for h i r i n g out g u a r d s for a small weekly s u m . M o r e care s h o u l d b e t a k e n in t h e r e c o n s t r u c t i o n of old houses. O f t e n a n e w fireplace is fitted a n d the space at the back filled w i t h any r u b b i s h , w h i c h m a y catch fire. A friend of m i n e noticed s m o k e c o m i n g f r o m the side of h e r fireplace one m i d - d a y . T h e r e h a d b e e n n o fire in t h e grate since t h e previous n i g h t . H e r b a b y slept in t h a t r o o m alone. T h e firemen f o u n d a large fire b e h i n d the grate w h e n they pulled it o u t a n d told h e r this was a c o m m o n occurrence. S o m e n e w houses b u i l t b y local authorities have a fire in the sitting r o o m w i t h t h e c h i m n e y g o i n g u p t h r o u g h the centre of t h e h o u s e so t h a t heat is n o t lost o n an outside wall. Care m u s t be t a k e n in c o n s t r u c t i n g this flue. [ k n o w of two such houses w h e r e b e d r o o m f u r n i t u r e has b e e n destroyed t h r o u g h fire s t a r t i n g in the chimney. All t h e n e i g h b o u r s n o w k n o w t h e risk a n d t h a t t h e y c a n n o t have large fires in t h e grate for long periods. T h e possibility of w o r n electric wires s t a r t i n g fires is well k n o w n b u t little heeded, a n d m a j o r electrical alterations are o f t e n e n t r u s t e d to amateurs. I was told of a certified m e n t a l defective t h a t h e was marvellous w i t h electricity a n d d i d all t h e n e i g h b o u r s ' electrical repairs. M a n y scalds are due to p a n s b e i n g k n o c k e d off t h e t o p o f gas stoves. I f all t h e b u r n e r s are in use at t h e same time, as in cooking a family d i n n e r , t h e p a n h a n d l e s m u s t project b e y o n d the edge of t h e gas stove. I f they do n o t t h e y get very hot. I n D e n m a r k t h e y appear n o t to use gas cookers such as we have here : t h e y have a m e t a l - t o p p e d t a b l e with a n u m b e r of m o v a b l e gas rings o n it, w h i c h can b e a d j u s t e d so t h a t t h e r e is p l e n t y of space b e t w e e n t h e p a n s a n d t h e r e is r o o m to s t a n d the p a n s o n the table w h e n t h e y are t a k e n off the rings. T h e oven is a separate box at table height. T h e a r r a n g e m e n t takes u p m o r e r o o m a n d js n o t so nice to look at as o u r gas cooker b u t it is easier a n d safer to work with. T h e r e is n o d a n g e r of p a n s b e i n g knocked over so t h a t t h e i r c o n t e n t s are spilled over a n y o n e s t a n d i n g near. H o t w a t e r appliances s h o u l d b e regulated so t h a t t h e y c a n n o t p r o d u c e water t h a t will scald. W h e n one considers t h e difficulty of cooking-on.,an o r d i n a r y sitting r o o m grate b y the m o t h e r of a family living in o n e or two rooms, o n e is n o t s u r p r i s e d t h a t fish a n d chips a n d food f r o m tins f o r m t h e s t a n d a r d meals. It is t e m p t i n g P r o v i d e n c e to heat p a n s a n d kettles on such a grate w i t h small c h i l d r e n about. I t requires a very clever p e r s o n to m a n a g e u n d e r s u c h conditions b u t usually it is t h e duller ones w h o have to do so, I n schools usually t h e m o s t expensive m o d e r n fittings are p u t into t h e rooms w h e r e girls learn housework. I t is easy to learn to use these. It w o u l d b e b e t t e r to c o n c e n trate o n t e a c h i n g t h e m h o w to m a n a g e w i t h the m i n i m u m a n d to improvise a n d work in c o n d i t i o n s w h i c h t h e y m a y have in t h e i r o w n homes. Between 400 a n d 500 p e r s o n s die each year f r o m accidental p o i s o n i n g w i t h coal gas, m o s t of t h e m in t h e i r o w n h o m e s a n d t w o - t h i r d s of t h e m over 60 years of age. T h e chief causes are partly t u r n e d off gas taps, so t h a t t h e flame goes out, poor ventilation, blocked flues a n d w o r n out a p p a ratus. T h e d a n g e r of u s i n g a gas fire w i t h o u t adequate v e n t i lation is often n o t appreciated. M a n y rooms are n o w b u i l t w i t h o u t fireplaces a n d the occupants f r e q u e n t l y block t h e wall ventilator. Gas fires s h o u l d n o t be u s e d in s u c h rooms. Last w i n t e r two w o m e n a n d four c h i l d r e n were f o u n d u n c o n s c i o u s a n d only two recovered. T h e y were in a r o o m w h e r e t h e c u r t a i n s h a d b e e n d r a w n a n d the gas fire p u t o n the m a n t e l p i e c e out of t h e way of the children.
119 G a s taps s h o u l d n o t be so loose they can be t u r n e d o n inadvertently. Gas a n d electricity authorities will s e n d an i n s p e c t o r to test t h e appliances in any house o n request, b u t those w h o are m o s t d o u b t f u l a b o u t t h e i r e q u i p m e n t will n o t ask for this to be done as t h e y are fearful of the expense that m a y be i n c u r r e d as a result. D r u g s cause t h e next greatest n u m b e r of deaths f r o m p o i s o n i n g a n d most, if n o t all, accidents of this k i n d could be avoided if medicine, cleaning materials a n d o t h e r d a n g e r o u s substances were kept in a safe place w h e r e c h i l d r e n could n o t get t h e m a n d adults would have to b e wide awake and alert to get t h e m . So m a n y children have b e e n p o i s o n e d b y eating tablets such as those c o n t a i n i n g ferrous s u l p h a t e t h a t it was considered recently that m e d i c i n e s h o u l d n o t be dispensed in this form, so easily m i s t a k e n by c h i l d r e n for sweets. B u t the p u b l i c has got used to its s u g a r - c o a t e d pill. G o n e are t h e days of the doctor's " g o o d bottle of m e d i c i n e " a p p a r e n t l y m i x e d b y his o w n h a n d w i t h t h a t little extra a d d e d for " t h e pain in m y back " or " this c o u g h . " I t has b e e n succeeded b y t h e t a b l e t f r o m the c h e m i s t often d e m a n d e d b y t h e patient. T h e bottle of m e d i c i n e could be s h o w n to the family a n d visitors, held u p to t h e light, shaken, s m e l t a n d even tasted and everyone could guess its composition. S o m e older people still pathetically e x h i b i t t h e i r tablets b u t t h e y vary little in appearance a n d n o t h i n g interesting can b e d o n e w i t h t h e m except c o u n t t h e m . I t h i n k doctors have t h r o w n away a very valuable w e a p o n in t h e psychological t r e a t m e n t of t h e i r p a t i e n t s and it is p e r h a p s significant t h a t h o m e o p a t h y is increasing. H o w e v e r , we m i g h t as well t r y to stop road accidents b y s t o p p i n g all traffic as stop p o i s o n i n g accidents b y t r y i n g to b a n t h e s e tablets. W h a t m u s t b e d o n e is make people aware of t h e d a n g e r a n d t h a t t h e y m u s t protect t h e i r c h i l d r e n f r o m it. T h e d e a t h of a h e a l t h y n o r m a l child is a whole life t h r o w n away. " C u t is the b r a n c h that m i g h t have g r o w n full s t r a i g h t . " I n all p r o p a g a n d a work we m u s t r e m e m b e r t h a t we live in an age of exaggeration. T h e ear is t u n e d to t h e l o u d speaker, the eye to see in gorgeous T e c h n i c o l o r , n o t i m e can b e spared to s t u d y details, a n d people b o a s t of t h e n u m b e r of t h i n g s t h e y can do at t h e same time. T h e r e f o r e , it is n o use h a n g i n g u p a notice or giving people a leaflet a n d expecting t h e m to read it. T h e r e m u s t b e a poster w i t h an appropriate picture a n d a few simple w o r d s s u c h as " Y o u r m e d i c i n e b u t his Poison. K e e p medicines locked u p . " I t occurs to m e t h a t d r u g a n d b a b y food m a n u f a c t u r e r s , w h o u n d e r s t a n d so well the art of advertising, m i g h t be p e r s u a d e d to take part. T h e y could c o m b i n e it w i t h an a d v e r t i s e m e n t s u c h as " T a k e A & B for your h e a d a c h e b u t d o n ' t let b a b y have it " or " Feed your b a b y o n X food b u t lock y o u r medicines away." Accidental s m o t h e r i n g in b e d or cot is m o r e likely to h a p p e n to a b o y t h a n a girl baby. N o reason has b e e n a d v a n c e d for this. It is always claimed t h a t w o m e n have m o r e highly developed instincts a n d intuitions t h a n m e n a n d rely on these r a t h e r t h a n r e a s o n i n g power, w h i c h t h e y are said to lack. P e r h a p s this i n s t i n c t tells t h e b a b y girl she is s m o t h e r i n g a n d induces her to t u r n over. A n o t h e r " M i s t l e t o e " B o u g h accident is h a p p e n i n g in America w h e r e in 12 m o n t h s 85 c h i l d r e n have died t h r o u g h h i d i n g in a b a n d o n e d ice boxes a n d b e i n g u n a b l e to get out. T w o bills are n o w before Congress m a k i n g it illegal to s u p p l y any ice box or refrigerator " u n l e s s it is e q u i p p e d w i t h a l a t c h w h i c h enables it to be o p e n e d f r o m t h e i n s i d e . " T w e n t y States have m a d e it illegal to " a b a n d o n a n ice box w i t h o u t first r e m o v i n g the d o o r or l a t c h . " P e r h a p s we shall n e v e r reach the stage of t h r o w i n g away ice boxes in this c o u n t r y b u t i t is as well to b e f o r e w a r n e d of t h e danger. W h i l e I have b e e n s u m m a r i s i n g the m a i n types of h o m e accident a n d t h e i r causes you will have t h o u g h t of m a n y more. P r e v e n t i v e m e d i d i n e has b e c o m e increasingly d i r e c t e d to i m p r o v i n g t h e resistance to disease r a t h e r t h a n r e m o v i n g t h e causes, a n d m e d i c a l officers a n d h e a l t h visitors devote m o r e a n d m o r e of t h e i r time to i m m u n i s i n g and vaccinating.
P U B L I C H E A L T H , M a y , 1955
120 T h e n u m b e r of cards a n d f o r m s t h e h e a l t h visitor has to fill in a n d i n d e x leaves h e r little time for t h e w o r k for w h i c h she has b e e n t r a i n e d - - e . g , itTis necessary for t h e n a m e a n d address of a n e x p e c t a n t m o t h e r to b e w t i t t e n o u t n i n e t i m e s t h e first time she attends t h e clinic if she wishes to take a d v a n t a g e of all the facilities available 9 T h e liability to have a n accident m a y be decreased b y s u c h t h i n g s as w e a r i n g correct spectacles, h e a r i n g aid, u s i n g w a l k i n g stick a n d wearing cbrrect shoes b u t t h e p u b l i c m u s t also b e e d u c a t e d so t h a t they k n o w t h e causes of accidents a n d can recognise defects in t h e i r o w n h o m e s or h a b i t s a n d rectify t h e m themselves. T h i s is n o t easy work. As t h e G r e e k p h i l o s o p h e r Heraclitus said " t h o u g h reason is accessible to all, m o s t people, it seem.s, incline to live according to t h e i r o w n n o t i o n s . " Throughout nature the mother protects her young from d a n g e r a n d educates t h e m for life. T h e m o t h e r of t h e child will b e anxious to protect it f r o m accident if the n e e d is explained to her. T h i s is particularly t r u e of t h e expectant p r i m i p a r a w h o s e m i n d is i n a v e r y receptive state. S h e is anxious to prepare for the c o m i n g b a b y a n d has t i m e to plan h e r h o m e so t h a t it will b e suitable for t h e child w h e n it starts to walk. A f t e r t h e b a b y is b o r n its g r o w t h is so rapid that t h e m o t h e r is so occupied t h a t it m a y b e o n its feet a n d into t h e fire before t h e n e e d for a fireguard has b e e n realised. T h e m o t h e r could also c o n d i t i o n h e r s e l f to good h a b i t s so that, for example, s h e w o u l d n e v e r p o u r hot w a t e r into an e m p t y bowl. W o m e n ' s organisatioils are particularly i n t e r e s t e d in t h e p r e v e n t i o n of h o m e accidents a n d w o u l d welcome advice o n w h a t to d o ' b e f o r e t h e accident, for they are t h e people m o s t likely to have a n accident. T h e radio, television, newspapers, t h e c i n e m a a n d w o m e n ' s magazines c a n all play t h e i r p a r t , i n e d u c a t i n g t h e p u b l i c as t h e y o f t e n do n o w i n R o a d Safety C a m p a i g n s . H o m e Safety C o m m i t t e e s are increasing in n u m b e r s , s p o n s o r e d b y t h e Royal Society for t h e P r e v e n t i o n of Accidents. G e n e r a l practitioners a n d c o n s u l t a n t s show great i n t e r e s t in this subject a n d a w h o l e n u m b e r of t h e P r a c t i t i o n e r was recently d e v o t e d to A c c i d e n t P r e v e n t i o n . T h e B . M . A . in its e v i d e n c e to t h e W o r k i n g P a r t y of H e a l t h Visitors this year a d d e d to t h e subjects suggested as suitable for h e a l t h e d u c a t i o n " t h e i m p o r t a n c e of e d u c a t i o n in accident p r e v e n t i o n , w i t h special reference to accidents in t h e h o m e . " B u t p r e v e n t i o n of disease is o n e of t h e chief r e s p o n sibilities of t h e M e d i c a l Officer~-of H e a l t h a n d his staff. T h e a m b u l a n c e service, t h e h o m e n u r s e a n d the h o m e help m a y all b e n e e d e d for the t r e a t m e n t of a h o m e accident a n d it is therefore even to t h e advantage of a h e a l t h d e p a r t m e n t itself to r e d u c e t h e n u m b e r of these accidents. Since I qualified m a n y changes a n d i m p r o v e m e n t s in t h e general h e a l t h of t h e c o m m u n i t y have b e e n achieved w h i c h t h e n s e e m e d impossible a n d c o m p a r e d w i t h these t h e reduction of h o m e accidents s h o u l d b e relatively simple. W i l l i a m Harvey, said " Civilisation is s i m p l y a series of victories over n a t u r e " a n d so t h a t we m a y leave this p r o b l e m in its t r u e perspective I w o u l d r e m i n d you t h a t in 1,500 the expectation of life at b i r t h was 30 years a n d L e o n a r d o da V i n c i was r e g a r d e d as an old m a n w h e n h e died at the age of 69. T h e expectation of life at b i r t h n o w is 70 years. B u t J e r e m y T a y l o r ' s r e m a r k is still t r u e " T o preserve a m a n alive in t h e m i d s t of so m a n y chances a n d hostilities is as great a miracle as to create h i m . " REFERENCES
LANE, MARGARET. T h e Bront~ Story. Accidents in the H o m e - - R e p o r t of the Standing Inter-departmental Conmaittee on Accidents in the Home. H.M. Stationery Office 1953. Memorandum of Evidence to Working Party on Health Visitors. (1954). B r i t . M e d . ~ . S u p p l e m e n t , i, 268.~ SIMPSON, KEITH. T h e Danger of Accidental Carbon Monoxide Poisoning. (October 2nd, 1954). B r i t . M e & J , ii, 774. Report of Registrar General. Medical Statistics, 1952.
By
T H E EPIDEMIOLOGY OF H E A L T H * JOHN LANDOR, M.R.C.S., L.R.C.P., D.P.H., M e d i c a l Officer o / H e a l t h ,
Borough
o/Bexley
T h e use of t h e expression " epidemiology of h e a l t h " h a s still to be d e f e n d e d in t h i s c o u n t r y a l t h o u g h i t h a s g a i n e d a s o m e w h a t wider c u r r e n c y in t h e U . S . A . I first saw it used in I948 in a l e t t e r f r o m t h e late Professor J o h n R y l g who had, t h e n , r e c e n t l y r e t u r n e d f r o m a lecture t o u r in A m e r i c a u n d e r t h e auspices of t h e Rockefeller F o u n d a t i o n . T h e first r e a c t i o n t h a t t h i s i n v o k e d was one of surprise a n d some concern t h a t t h e word " epidemiology " s h o u l d be j u x t a p o s e d to " h e a l t h " a n d not, in t h e c u s t o m a r y m a n n e r , t o " d i s e a s e . " G r e a t e r f a m i l i a r i t y w i t h t h e idea, however, n o t o n l y r e m o v e d t h e s e misgivings b u t b r o u g h t , in t h e i r place, a feeling of e m a n c i p a t i o n as b y t h e r e m o v a l of a n intellectual s t r a i t - j a c k e t a n d of a cold a n d i n v i g o r a t ing wind blowing d o w n t h e corridors of t r a d i t i o n a l practice. T h e first difficulty is of a n e t y m o l o g i c a l n a t u r e . I n 1952, Prof. A. G. G a r d n e r , of Oxford, a n a u t h o r i t y on t h e m e a n ing of words, p r o t e s t e d a g a i n s t w h a t he called t h e " undoubted debauchery of a precise word 'epidemiology ' ~ h i c h is being inflated b y writers on social medicine and similar subjects to include the study of the frequency or incidence of diseases whether epidemic or not. The right and 9 . . obvious meaning of ' e p i d e m i o l o g y ' is given b y the Shorter Oxford Dictionary as ' t h e Study of epidemics' and of an ' epidemic ' as a disease prevalent among a people or a community at a special time a n d produced b y some special causes not generally present in t h e affected locality.' Therefore to speak of the epidemiology of coronary thrombosis, or of hare-lip or diabetes' or of any non-epidemic disease is a debasement of the currency of thought. I t is no use saying t h a t the word is being used in its wider sense. It has no wider sense." I f this o b j e c t i o n is valid, " t h e r e w o u l d b e a n even g r e a t e r o b j e c t i o n to t h e a p p l i c a t i o n of t h e word " epidemiology " to h e a l t h . Greenwood, on t h e o t h e r h a n d , h a s p o i n t e d o u t t h a t epidemiology suggests, b y its derivation "a science of s o m e t h i n g falling u p o n t h e people a l t h o u g h it c a m e t o m e a n t h e s t u d y of disease, a n y disease, as a m a s s p h e n o m e n o n . " T h i s c o n t r o v e r s y is, of course, m u c h m o r e t h a n a m a t t e r ' o f m e r e semantics. M a n y infectious diseases h a v e b e e n v i r t u a l l y abolished as a result of a knowledge of t h e i r e p i d e m i o l o g y a n d if, for instance, c o r o n a r y t h r o m b o s i s a n d c a n c e r could b e s h o w n to h a v e a n epidemiology of t h e i r own, t h e e m p h a s i s would, inevitably, shift from cure t o p r e v e n t i o n . Similarly, if h e a l t h could b e s h o w n t o h a v e a n e p i d e m i o l o g y t h e e m p h a s i s would shift still f u r t h e r in t h e d i r e c t i o n of p r o m o t i o n . However, t o s u p p o r t s u c h a t h e s i s i t would b e n e c e s s a r y to show t h a t h e a l t h can, in fact, descend on a c o m m u n i t y p e r h a p s b y t h e a p p l i c a t i o n of a s y s t e m of social h y g i e n e w h i c h t h e late Professor R e n e S a n d defined as " t h e integ r a t i o n of m e d i c a l a c t i o n w i t h a collective c o m m u n a l discipline." Before t h i s c a n be done, however, c e r t a i n epidemiological similarities a n d differences b e t w e e n h e a l t h a n d disease m u s t be considered. T h e p h e n o m e n a of h e a l t h a n d disease h a v e this in comm o n : t h a t t h e y are b o t h links in a n epictemiological c h a i n of e v e n t s w h i c h m a y go b a c k days, or m o n t h s , or years. To t a k e specific instances, we k n o w little of t h e precursors of influenza or t h e reasons for t h e periodic recurrence of epidemics. I t is g e n e r a l l y held t h a t c o n t r i b u t o r y causes m a y b e meteorological changes, t h e a c c u m u l a t i o n of a large reservoir of susceptible persons, t h e presence of a n approp r i a t e s t r a i n of v i r u s w i t h , possibly, a n e x a l t a t i o n of virulence. I t is possible, therefore, t h a t w h a t seems to b e t b e s u d d e n descent of influenza on a p o p u l a t i o n is t h e r e s u l t of t h e i n t e r a c t i o n of m a n y f a c t o ~ w h i c h are in t h e m s e l v e s r e l a t i v e l y slow moving 9 Similarly t h e explosive n a t u r e of a n o u t b r e a k of w a t e r - b o r n e t y p h o i d fever m a y disguise t h e fact t h a t t h e w a t e r s u p p l y m a y h a v e b e e n sewage p o l l u t e d *Paper read to the Metropolitan Branch, Society of M.O.H., March I l t h , 1955.