Adoption

PUBLIC

HEALTH

SOCIETY OF MEDICAL OFFICERS OF HEALTH Telephone: EUSton 3 9 2 3

TAVISTOCK HOUSE, TAVISTOCK SQUARE, LONDON, W.C.I

Telegrams: Epidauros, Westcent

No. 11. Vol. LXV

AUGUST, 1952 CONTENTS PAGE

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EDITORIAL Adoption Cancer

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Ass'~ssing Men a n d J o b s r.i)., M.B.j D.P.H . .

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CORRESPONDENCE Preventive Psychiatry

SPECIAL ARTICLES T n b e r c u ' o s i s a n d the MB., B.CH., D.P.H .

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S o m e H e a ' t h A s p e c t s of N a t i o n a l Service. 13~- Lt.-Col. R W. Scott, O.E.L, .XI.B., R . A . M . C . . .. . . . . . .. Y o u t h in I n d u s t r y : to N a t i o n a l S e r v i c e a n d B a c k . B y ]'. A D u n c a n , M.B., CH.B . . . . . . . . . . .

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EDITORIAL

Adoption A legal process that radically affects the lives of upwards of 20,000 children every year in England and Wales is one that must be of interest and concern to every Medical Officer of Health. T h a t process is adoption which, legalised in 1927, has rapidly become more popular until to-day it is almost a fashion. Miss Margaret Kornitzer's book, " Child Adoption in the Modern World,"* is a fascinating account of almost every aspect of adoption, including foreign practice and experience. As Press Officer of the Standing Conference of Adoption Societies she is in a good position to put the ease for adoption and to describe both the legal and practical problems involved and she has done it well. Most of us would support the view that where the child is inevitably to be separated permanently from the mother and its home adoption is almost invariably the best course in the interest of the child : but we think Miss Kornitzer starts off on the basis that in almost every case of illegitimacy adoption is the solution of choice if any difficulty arises. With this we disagree. T h u s she writes : " But although a mother will sometimes find it possible to manage with a baby for a while, with the years she usually finds it not easier but more difficult. Unless she is perfectly sure of her own courage and unimpaired earning p o w e r I w h i c h as a rule means being sure of her relations and friends as well as of herself--it is often better to decide on adoption as early as possible, dreadful wrench though this is." Reflections of that sort might well be advanced against adoption itself and with as little reason. We have advocated in this journal that every practical step should be taken to keep the mother and infant together : we believe that the health authorities are, generally speaking, failing in this matter, failing to provide the help they could offer by way of hostel accommodation, adequate day nursery provision and other forms of assistance, and that the State itself could do much more than it does financially to help the unmarried mother. T o keep mother and baby together does not encourage profligacy or illegitimacy--it would do quite the reverse. Adoption is a simpler course than what we advocate, and that in itself should make Us beware of accepting it blindly as the best thing. Everyone knows that arrange]]~ltl~j"~ adoptions are often initiated before the baby i ~ ( P ~ that we believe is thoroughly bad practice. / f ~ l ~ l ~ h e mother cannot give legal consent for a d o p t i o ~ e f o r ~ h e baby is six weeks old, a wise provision, but i t ~ ' l S ~ p ~ ! * (Pp. 403. Price 16s.) London : Putnam & Co. ]~r{~_~2

R i v e r P o l l u t i o n - - t h e B u c k l a n d L e c t u r e s ( H . D. H3"gQrne ( J . R . B u s v i n e ) . . . . . . . .

Turin~; Insects . . . .

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SOCIETY OF MEDICAL OFFICERS OF HEALTH The Annual Dinner .. New South Wales Branch Services Group . . .

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frustrated when the baby is placed at an earlier date, as is sometimes done. T h e demand for babies now exceeds the number for whom adoption is sought. Figures are not available for this country but if our experience matches Australia's, and we see no reason to believe to the contrary, a very considerable proportion of adoptions take place before the first birthday. One difficult problem is that of telling the child he has been adopted. It is the crucial one in many cases, the solution to which may make all the difference between, on the one hand, a happy child and happy family and, on the other, general wretchedness. Most of us agree that the child should be told early in its new life, naturally, affectionately, truthfully and prudently. There were in 1949 17,331 adoptions in England and Wales ; and there were (though the figures are not directly related at all) some 35,000 illegitimate children born. It must be remembered that many adoptions are by mothers of their own illegitimate children--up to 70% in some areas I to secure to the children certain advantages otherwise denied them, such as status for pension and family allowance purposes. We do not know what proportion of adoptions were of children of unmarried women. But we find it difficult to understand why adoption should be necessary except perhaps in regard to inheritance as of right of the mother's husband's goods. It has been said that there are no illegitimate children but only illegitimate parents. Everything that is possible should be done for the child, and in our view this involves much help for the mother, at least in the child's early years when the basis of his health, both mental and physical, is being laid. T h a t deprived children have been better cared for since 1948 is an undisputed fact. But it is worth emphasising that local authorities have spent much more, and have been compelled by the Home Office to spend much more, than they were willing to do when the care of their children largely fell on the Health Department. Sir Ernest Cassels is reported to have said at the outset of World War I, " If money is wanted, money will be found," but that is not true in the local health services. T o revert to adoption : one thing " stands out a mile," and that is how little we really know about the late results of adoption. T h e register of adopted children is open for inspection hut quite properly full regard must he given to the right of both the child and its substitute parents to privacy and security: that makes it difficult to get the necessary information. It is important, however, both to this and succeeding generations to know the full effects of adoption. T h e National Association foi~ Mei~/tal Health is

PUBLIC HEALTH, August, 1952

180 u n d e r s t o o d to be u n d e r t a k i n g r e s e a r c h on these lines : we feel sure t h a t this will b e a n i m p o r t a n t a n d r e w a r d i n g task.

Cancer Registration I n 1940 t h e G e n e r a l Register Office p u b l i s h e d a booklet b y D r . P e r c y Stocks o n " C a n c e r R e g i s t r a t i o n i n E n g l a n d a n d Wales " (Studies o n M e d i c a l a n d P o p u l a t i o n Subjects, No. 3). I n it a d e s c r i p t i o n of t h e C a n c e r Records S c h e m e a n d its p u r p o s e was followed b y a series of tables s h o w i n g for c a n c e r of each p a r t of t h e b o d y t h e n u m b e r of p a t i e n t s registered in 1945 a n d 1946. A m o n g t h e analyses m a d e was one s h o w i n g t h e c o n d i t i o n at t h e e n d of a year of p a t i e n t s w i t h p r i m a r y cancer. I n s u p p l e m e n t a r y tables to t h a t S t u d y , n o w p u b l i s h e d , * are g i v e n t h e c o r r e c t e d Survival a n d R e c o v e r y Rates at t h e first a n d s e c o n d a n d provisional rates at t h e t h i r d anniversaries of t r e a t m e n t for cases of p r i m a r y c a n c e r registered d u r i n g 1945 a n d 1946, at t h e m o r e i m p o r t a n t sites. T h e s e tables, in c o n j u n c t i o n w i t h t h e original booklet, give useful i n f o r m a t i o n o n t h e p r o s p e c t s of survival of c a n c e r p a t i e n t s in relation to t h e different sites of the disease, its several stages of d e v e l o p m e n t a n d t h e various m e t h o d s e m p l o y e d in t r e a t m e n t . A c o m p l e t e a n d accurate p i c t u r e c a n n o t , however, b e g i v e n u n t i l t h e u l t i m a t e a i m of registering a n d following u p all n e w eases of c a n c e r is achieved. F u r t h e r i n f o r m a t i o n will b e p u b l i s h e d later w h e n details a b o u t the p a t i e n t s ' c o n d i t i o n at the e n d of four a n d five years b e c o m e available.

Decentralisation Shortly after the publication in this journalf of the short statement of policy by the Society on decentralisation of N.H.S. Part III functions there has followed that of a study$ carried out by an officer of the Institute of Public Administration, Miss E. W. Cohen, which covers both delegation under the Education Act, 1944, and decentralised administration under the National Health Service Act, 1946. As Professor William Robson points out in a foreword, the two recent trends in British local government have been the transfer of services from L.A.s to central departments and public corporations and the shift of power in administrative counties from the districts to the county councils. By a typical English device actuated by the instinct to compromise (or perhaps fair play?) the shift of powers to the counties has been qualified by a return of limited administrative functions tO the smaller units, in the hope that local interest will be maintained. Miss Cohen and the Institute have performed a useful service in preparing this first survey of the present position regarding delegation or decentralisation of functions under the Education Act, 1944, and National Health Service Act, 1946 (not forgetting Circular 118/47!). This Society is naturally inclined to look at the problem from the point of view of medical officers of health whose careers have been so rudely jolted by recent statutes. But the whole matter also lies very close to the well- or ill-being of local government and deserves close study by all concerned, whether elected representatives or officers. To quote again from Prof. Robson's foreword, " If delegation is to be no more than mere agency, it will contain neither the substance nor the spirit of our system of local self-government."

* Studies on Medical and Population Subjects. Supplement to No. 3, Car/cer Registration in England and W a l e s - - T h i r d Year Recovery and Survival Rates. H.M.S.O., price ls. 3d. net (or by post from P.O. Box 569, London, S.E.1 ; price ls. 4~d.).

~f PUBLIC HEALTH (June, 1952). 65. 161. + Autonomy and Delegation in County Government. A study of delegation in edacation and local health administration. By Emmeline W. Cohen. (Pp. 81. Price 6s. net. The Society of M.O.H. holds a limited number of copies available to members at the special ,price of 4s. 6d. post free. London: Institute of Public Administration, 76a New Cavendish Street, W.I, 1952.

TUBERCULOSIS

AND THE MEDICAL OFFICER OF HEALTH * By F. G . BROWN, M.B., B.CH., D.P.H. 2Vledical Qfficer of Health, lCanstead 6.~ lVoodford M . B . ; Area Medical Officer, Essex. W h e n you h o n o u r e d m e b y electing m e y o u r P r e s i d e n t , I realised t h a t one of m y duties was to deliver a n address. R a t h e r t h a n give a f o r m a l presidential address w h i c h c o u l d n o t b e followed b y a discussion, I t h o u g h t it w o u l d b e p r e f e r a b l e for m e to speak o n a s u b j e c t w h i c h is one of o u r c h i e f c o n c e r n s in the p u b l i c h e a l t h w o r l d to-day, namely, tuberculosis, a n d that, following m y talk, m e m b e r s m i g h t express t h e i r views, n o t only f r o m t h e angle of the M e d i c a l Officer of Health, b u t also f r o m t h a t of t h e C h e s t Physician. I a m one of t h o s e w h o e n t e r e d the s p h e r e of general p u b l i c h e a l t h h a v i n g g r a d u a t e d in t h e t u b e r c u l o s i s service. I n d e e d , h a d it n o t b e e n for the war, I s h o u l d , i n all p r o b a bility, b e d o i n g clinical tuberculosis w o r k to-day. I t is of i n t e r e s t to look back over t h e past 20 years a n d to o b s e r v e t h e c h a n g e s w h i c h h a v e t a k e n place in t h e t u b e r c u l o s i s service, n o t only i n a d m i n i s t r a t i o n a n d in i m p r o v e d m e t h o d s of t r e a t m e n t , b u t also i n t h e outlook of t h e patient. P r i o r to t h e N a t i o n a l H e a l t h Service A c t of 1946, t h e whole of t h e service in b o t h its p r e v e n t i v e a n d curative aspects was vested in the L . H . A . , others c o n c e r n e d b e i n g t h e G . P . , certain v o l u n t a r y hospitals specialising in diseases of t h e chest, a n d v o l u n t a r y organisations c a r r y i n g o u t w o r k o f care a n d after-care. Now, as we are only too well aware, t h e p r e v e n t a t i v e a n d curative fields have, in the m a i n , b e e n s e p a r a t e d b y t h e e s t a b l i s h m e n t of t h e Regional H o s p i t a l Boards. W h e n I was first c o n c e r n e d w i t h t h e t r e a t m e n t of p a t i e n t s in sanatoria suffering f r o m p u l m o n a r y t u b e r c u l o s i s t h e a u t o - i n t o x i c a t i o n t h e o r y of t h e late M a r c u s P a t t e r s o n was d y i n g v e r y h a r d . P a t i e n t s w i t h e x t e n s i v e active bilateral disease were allowed to get o u t of b e d a n d take exercise, p r o v i d e d t h e i r t e m p e r a t u r e s were b e l o w 99 ° . R e g u l a r x-ray c o n t r o l was t h e exception r a t h e r t h a n t h e rule. I n d e e d , t h e asking for a n x-ray e x a m i n a t i o n to b e carried o u t o n a d i s p e n s a r y p a t i e n t as a n aid to diagnosis was h e l d to b e a confession of i n d i f f e r e n t clinical ability. Collapse t h e r a p y was in its i n f a n c y a n d was often carried o u t in i n s t i t u t i o n s w i t h o u t x-ray plant. I n t h e early 1930s rapid strides were m a d e in the i m p r o v i n g of e q u i p m e n t in m a n y s a n a t o r i a a n d hospitals. Artificial p n e u m o t h o r a x t r e a t m e n t was greatly a d v a n c e d b y t h e division of a d h e s i o n s a n d c h e s t s u r g e r y was b e g i n n i n g to come into its own. A b o v e all, t h e i m p o r t a n c e of p r o l o n g e d b e d rest, irrespective of w h a t active t r e a t m e n t was in operation, was b e i n g realised. W i t h the o n s e t of w a r i n 1939 came a great setback. All p a t i e n t s w h o c o u l d get o u t o f b e d a n d walk were d i s c h a r g e d f r o m i n s t i t u t i o n s to t h e i r h o m e s . N o t only was t h e i r t r e a t m e n t i n t e r r u p t e d w i t h disastrous results, b u t t h e y were t h e m e a n s of s p r e a d i n g i n f e c t i o n t h r o u g h o u t t h e c o m m u n i t y at large. W h e n a d m i s s i o n s were again possible, m a n y i n s t i t u tions h a d to take in cases f r o m t h e a r m e d forces n o t n o r m a l l y r e s i d i n g i n t h e districts w h i c h t h e i n s t i t u t i o n served. F o r e i g n troops, p a r t i c u l a r l y Poles, w h i c h h a d arrived i n t h e c o u n t r y , were f o u n d to b e suffering f r o m t u b e r c u l o s i s a n d to require i n s t i t u t i o n a l t r e a t m e n t . D u r i n g t h e w a r t h e discovery of t h e s u l p h a d r u g s a n d penicillin caused a greatly r e d u c e d m o r t a l i t y i n chest s u r g e r y where, previously, t h e a d v e n t o f sepsis h a d often led to c h r o n i c i n v a l i d i s m a n d to fatal results. I n r e c e n t years t h e use of a n t i b i o t i c d r u g s i n selected cases has b r o u g h t a b o u t t h e a r r e s t of s p r e a d of disease a n d h a s greatly l e s s e n e d infectivity b y r e n d e r i n g t h e s p u t u m negative. T h e u s e of s t r e p t o m y c i n , c o m b i n e d w i t h P A S , has m i n i m i s e d toxic s y m p t o m s . T h e s e d r u g s can b e of benefit as a p r e l i m i n a r y to, or a n a c c o m p a n i m e n t of, active m e t h o d s of t r e a t m e n t . T h e r e is, h o w e v e r , t h e d a n g e r of t h e d e v e l o p m e n t of s t r e p t o m y c i n - r e s i s t a n t strains of t h e * Presidential Address to the Home Counties Branch, Society of M.O.H., London, March 14th, 1952.