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General discussion
GENERAL DISCUSSION
275
General Discussion Dr. A. McGregor, Medical Officer q( IIealth, Couoty Borough of Southampton Lord Kennet referred to the idea that we ought to have free contraception on d e m a n d as superior to abortion, and I am sure that many of us would agree with him. The Secretary o f State has just produced a Circular indicating that in the interests of improving contraception the Government is going to release some millions o f money for domiciliary family planning services. Part of this will go through the Urban Aid Programme and will therefore in effect only come to certain areas of the country, and part of it will go on to the general grant. If Medical Officers are in fact to be able to improve contraceptive facilities in their area it is not enough to add to the general grant, because a fair number of councils will cheerfully receive grant aid and then use it for other purposes than contraception. Urban Aid. again, can only apply in those areas which can prove that they have immigrant populations o f such size that they quali~,.
Dr. F. R. itollins, Medical Officer of Health, City o.f New Sarum Lord Kennet in his address mentioned free contraception service for all. In this connection, and bearing in mind recent events, what do we regard as a lower age limit on this particular point ? Also what are his views on dealing with this subject of contraception at the linal secondary school leaving age ? •
.
F
This needs considerably study and discussion in depth between people with great experience of different aspects o f the matter. 1 would hope that the difficulty o f finding a sensible and h u m a n answer to that question would not be so great as to make it inadvisable or inhumane to go ahead with the idea of free contraception for all, as i was urging just now. One has to face the possibility that there is some chance that it might be impossible to find any sensible answer but I am not so pessimistic. I would say at all ages, infant, primary, and all the way up, sex education should just be part o f the normal picture of the world presented by teachers to children. " L o o k , we are h u m a n beings, and in c o m m o n with other mammals we reproduce in this way, just as we eat in this way, and just as we live in families thus composed and not otherwise, and the act o f love-making can be separated from the result of birth by various means, amongst which are the following." 1 would certainly avoid any approach like "Well, you are all going out into the world now, you are big children, we are going to reveal to you the secrets o f contraception", suddenly at the age o f sixteen.
Dr. Gordon, Deputy Medical Officer of Health, London Borough qf l'Vandsworth It has always amazed me why an important piece o f legislation like the National ~-~,~h Service Family Planning Act should be a permissive charge on local authorities. Ct ~:id L¢::,!'tt Kennet explain why it was not mandatory. Secondly. 1 would be grateful if Mr. Prestt could tell us whether any estimation o f the organo-chlorine c o m p o u n d content of birds that we prey on, has been estimated.
Lord Kennet It was not mandatory because there were and still are a number of M.P's with an important Catholic vote in their constituencies and also another number of M.P's with an important
276
PUBLIC HEALTH VOL. 85 NO. 6
sector of their voters who had the authoritarian personality which would have been offended by this whether or not they were Catholics. The proportion of M .P's who are in this position is of course declining all the time as the proportion of Catholics who hold to strict doctrine is now declining. And 1 think also that the proportion of the population at large which has the authoritarian personality is also declining,
Mr. Prestt Human food has been analysed very extensively. One of the dilticulties has been that no one will agree as to what is a reasonable maxim um i imit of any on e of these co mpo u n ds t h at should be allowed in food. Some countries, notably the United States, imposed a limit above which food would not be allowed to be sold on the market if it contained more than this amount, Other countries say that unless there is very good evidence for deciding this limit, this is a foolish approach. It is much better to try and keep the levels down as low as possible. ,An interesting conflict has arisen between the biologists and the medical people on the Advisory Committee. The levels in food and the levels in human beings generally are very small~only background levels. They are extremely small when compared with workers in the factories that produce Dieldrin and DDT and these other compounds. The view has bec~, understandably in many ways, that particularly in countries where you have insect borne disease, such as malaria and sleeping sickness, the enormous benefit produced by these compounds far outweighs the as not yet even demonstrated risk of small residues present in the body. To some extent the argument was then thrown back on to the conservationists to say what value you put on a peregrine falcon and a sparrow-hawk. The biologists tried to answer by saying "we are not just arguing from the point of view &preservation of species, but poiming out that these are indicators of environmental pollution. Is it right that persiste~t toxic compounds, even though they have'nt yet been shown to be harmful to human beings, shotJht be allowed to contaminate the environment?" In fact, the Advisory Committee in the end accepted this view that it is wrong to allow the environment to be contaminated by persistent toxic compounds.
Dr. Mary Paterson, DepuO' Medical Qffleer of Health, Cio' of WestmhTster I was fascinated by Lord Kennet's remark that perhaps some of the behavicur problems we meet in adolescents could be associated with circulating toxins, or toxic products. We have the fascinating example of lead poisoning in pica, :;,,nd one paediatrician I know holds that pica is caused by lead, rather than lead caused by pica, the two working rather together. We were also told that abnormal parental behaviour in birds can be caused ~t~y 'mgh " levels of certain other toxins. Now this leads one to fascinating thoughts about unusual parents and the unusual treatment of children, and to what extent there might be a poqsibility that our polluted'environment can be to some extent a factor in this.
Mr. Prestt I could perhaps say a little bit more about lhe abl~ormal behaviour in birtis, l~nmediately we discovered this parental egg breakage, we were anxious to know how it came about. Was it simply mechanical failure so that the birds rejected broken eggs, or did it represent a true abnormal behaviour, a term which might inciude ~, normal action appealing at the wrong ~me in the breeding c~cle, but we are fairly confident that in the heron it does represent an example of the birds' behaviour being affected.
Dr, J. MacLachlan, County Medical Officer, Mid,lothian I am thinking of things which are perhaps more humdrum than this morning's topics, such
GENERAl. D|SCUSS!ON
277
as clean beaches and clean air and the like. In the case of dirty beaches 1 was involved over a period o f a year in making a very intensive bacteriological study o f beach and river pollution. I reported to my Health Committee who agreed that something ought to be done to prevent all this po!lution--untii I told them that the solution was in fact a two million p o u n d sewering scheme. When the Clean Air Act came, we tried to get smokeless soft fuel burned. E v e r y o n e t h o u g h t we should, but when it came to expense we could not get it.. When we introduced hard coke we had to use smokeless appliances but we found they were expensive and up to now very little progress has been made in our particular authority. 1 remember many years ago an industrial town where there was a chemical factory producing a substance which was only made in that place in the United Kingdom. An offensive smell emanated from it and this smell permeated food to such an extent that it could not be eaten. The firm concerned did all that they could by spending thousands of pounds in washing the air as it went up the chimney, but this did not cure the trouble aj~d it was found that lhe only way to overcome it was by stopping the work. The people of this town, who were making a tremendous outcry, were then given lhe choice of your work or clean air-~nalurally they chose their work.
Lord Kennel 1 did not mean to say that the M.O.H. should stop his ears if his Council talked to him about the cost of his proposals, that he should refuse to mention the matter in his annual report, or that he should refuse to enquire into the cost o f what he thought might be a desirable remedial measure. I was saying rather that it was very wrong in my view for an M.O.H. to relrain ~ ~ml proposing what he thought was the best remedy because of its high expense. Cost judgement has to be made by the Council, or central Government, or whoever it may be. On one side there will be the firm--in the case o f the f a c t o r y - - o r the Borough Treasurer in the case o f a Town Council, saying "this cannot be done, it costs too much". On the other side we must then have the M.O.H. saying ,"All I tell you is that the health of the people is affected for the worse by this phenomenon, and that if this p h e n o m e n o n is reduced or removed it will no longer be so affected, over to you". if once the M.O.H. starts pulling his punches or softening his words because he knows there is a big expense involved, then the whole structure of decision making gets distorted. Dro C, D. L. Lyeett, Count)' Medical Officer, Wiltshire I do not think we should let the morning end without congratulating Lord Kennet on raising the question of noise. This is a subject which has been sparred with for m a n y years by Medical Officers o f Health and others who have tried to bring noise nuisance within the very a m o r p h o u s legislation on public health and c o m m o n law nuisances, and sparred with also by at least one Working Party. I would agree with Lord Kennet is suggesting that there is a degree of annoyance which can be called ill-health, from noise, but I would like to ask him how he would set about the problem of producing really workable, interpretable, and enforceable legislation on the subject. Lord Kennet This must be sector by sector. Let us make each successive generation o f aeroplane quieter than the one before. This is being done, or we are promised it is being done. There is the question fitting existing aircraft with quieter engines; I do not think any G o v e r n m e n t has bee~ br~ ve enough to enforce that yet but it could be done. So with cars.--imposing levels which ~ u s t be met by each successive generation o f cals and lorries on the roads.
278
PUBLIC HEALTH VOL. 85 NO. ~-,
Any Government will find it very much easier to do the right thing, and bring in tile right laws, if Medical Officers of Health in particular stand tip as one man and say "This you must do. Health is in danger".
275
General Discussion Dr. A. McGregor, Medical Officer q( IIealth, Couoty Borough of Southampton Lord Kennet referred to the idea that we ought to have free contraception on d e m a n d as superior to abortion, and I am sure that many of us would agree with him. The Secretary o f State has just produced a Circular indicating that in the interests of improving contraception the Government is going to release some millions o f money for domiciliary family planning services. Part of this will go through the Urban Aid Programme and will therefore in effect only come to certain areas of the country, and part of it will go on to the general grant. If Medical Officers are in fact to be able to improve contraceptive facilities in their area it is not enough to add to the general grant, because a fair number of councils will cheerfully receive grant aid and then use it for other purposes than contraception. Urban Aid. again, can only apply in those areas which can prove that they have immigrant populations o f such size that they quali~,.
Dr. F. R. itollins, Medical Officer of Health, City o.f New Sarum Lord Kennet in his address mentioned free contraception service for all. In this connection, and bearing in mind recent events, what do we regard as a lower age limit on this particular point ? Also what are his views on dealing with this subject of contraception at the linal secondary school leaving age ? •
.
F
This needs considerably study and discussion in depth between people with great experience of different aspects o f the matter. 1 would hope that the difficulty o f finding a sensible and h u m a n answer to that question would not be so great as to make it inadvisable or inhumane to go ahead with the idea of free contraception for all, as i was urging just now. One has to face the possibility that there is some chance that it might be impossible to find any sensible answer but I am not so pessimistic. I would say at all ages, infant, primary, and all the way up, sex education should just be part o f the normal picture of the world presented by teachers to children. " L o o k , we are h u m a n beings, and in c o m m o n with other mammals we reproduce in this way, just as we eat in this way, and just as we live in families thus composed and not otherwise, and the act o f love-making can be separated from the result of birth by various means, amongst which are the following." 1 would certainly avoid any approach like "Well, you are all going out into the world now, you are big children, we are going to reveal to you the secrets o f contraception", suddenly at the age o f sixteen.
Dr. Gordon, Deputy Medical Officer of Health, London Borough qf l'Vandsworth It has always amazed me why an important piece o f legislation like the National ~-~,~h Service Family Planning Act should be a permissive charge on local authorities. Ct ~:id L¢::,!'tt Kennet explain why it was not mandatory. Secondly. 1 would be grateful if Mr. Prestt could tell us whether any estimation o f the organo-chlorine c o m p o u n d content of birds that we prey on, has been estimated.
Lord Kennet It was not mandatory because there were and still are a number of M.P's with an important Catholic vote in their constituencies and also another number of M.P's with an important
276
PUBLIC HEALTH VOL. 85 NO. 6
sector of their voters who had the authoritarian personality which would have been offended by this whether or not they were Catholics. The proportion of M .P's who are in this position is of course declining all the time as the proportion of Catholics who hold to strict doctrine is now declining. And 1 think also that the proportion of the population at large which has the authoritarian personality is also declining,
Mr. Prestt Human food has been analysed very extensively. One of the dilticulties has been that no one will agree as to what is a reasonable maxim um i imit of any on e of these co mpo u n ds t h at should be allowed in food. Some countries, notably the United States, imposed a limit above which food would not be allowed to be sold on the market if it contained more than this amount, Other countries say that unless there is very good evidence for deciding this limit, this is a foolish approach. It is much better to try and keep the levels down as low as possible. ,An interesting conflict has arisen between the biologists and the medical people on the Advisory Committee. The levels in food and the levels in human beings generally are very small~only background levels. They are extremely small when compared with workers in the factories that produce Dieldrin and DDT and these other compounds. The view has bec~, understandably in many ways, that particularly in countries where you have insect borne disease, such as malaria and sleeping sickness, the enormous benefit produced by these compounds far outweighs the as not yet even demonstrated risk of small residues present in the body. To some extent the argument was then thrown back on to the conservationists to say what value you put on a peregrine falcon and a sparrow-hawk. The biologists tried to answer by saying "we are not just arguing from the point of view &preservation of species, but poiming out that these are indicators of environmental pollution. Is it right that persiste~t toxic compounds, even though they have'nt yet been shown to be harmful to human beings, shotJht be allowed to contaminate the environment?" In fact, the Advisory Committee in the end accepted this view that it is wrong to allow the environment to be contaminated by persistent toxic compounds.
Dr. Mary Paterson, DepuO' Medical Qffleer of Health, Cio' of WestmhTster I was fascinated by Lord Kennet's remark that perhaps some of the behavicur problems we meet in adolescents could be associated with circulating toxins, or toxic products. We have the fascinating example of lead poisoning in pica, :;,,nd one paediatrician I know holds that pica is caused by lead, rather than lead caused by pica, the two working rather together. We were also told that abnormal parental behaviour in birds can be caused ~t~y 'mgh " levels of certain other toxins. Now this leads one to fascinating thoughts about unusual parents and the unusual treatment of children, and to what extent there might be a poqsibility that our polluted'environment can be to some extent a factor in this.
Mr. Prestt I could perhaps say a little bit more about lhe abl~ormal behaviour in birtis, l~nmediately we discovered this parental egg breakage, we were anxious to know how it came about. Was it simply mechanical failure so that the birds rejected broken eggs, or did it represent a true abnormal behaviour, a term which might inciude ~, normal action appealing at the wrong ~me in the breeding c~cle, but we are fairly confident that in the heron it does represent an example of the birds' behaviour being affected.
Dr, J. MacLachlan, County Medical Officer, Mid,lothian I am thinking of things which are perhaps more humdrum than this morning's topics, such
GENERAl. D|SCUSS!ON
277
as clean beaches and clean air and the like. In the case of dirty beaches 1 was involved over a period o f a year in making a very intensive bacteriological study o f beach and river pollution. I reported to my Health Committee who agreed that something ought to be done to prevent all this po!lution--untii I told them that the solution was in fact a two million p o u n d sewering scheme. When the Clean Air Act came, we tried to get smokeless soft fuel burned. E v e r y o n e t h o u g h t we should, but when it came to expense we could not get it.. When we introduced hard coke we had to use smokeless appliances but we found they were expensive and up to now very little progress has been made in our particular authority. 1 remember many years ago an industrial town where there was a chemical factory producing a substance which was only made in that place in the United Kingdom. An offensive smell emanated from it and this smell permeated food to such an extent that it could not be eaten. The firm concerned did all that they could by spending thousands of pounds in washing the air as it went up the chimney, but this did not cure the trouble aj~d it was found that lhe only way to overcome it was by stopping the work. The people of this town, who were making a tremendous outcry, were then given lhe choice of your work or clean air-~nalurally they chose their work.
Lord Kennel 1 did not mean to say that the M.O.H. should stop his ears if his Council talked to him about the cost of his proposals, that he should refuse to mention the matter in his annual report, or that he should refuse to enquire into the cost o f what he thought might be a desirable remedial measure. I was saying rather that it was very wrong in my view for an M.O.H. to relrain ~ ~ml proposing what he thought was the best remedy because of its high expense. Cost judgement has to be made by the Council, or central Government, or whoever it may be. On one side there will be the firm--in the case o f the f a c t o r y - - o r the Borough Treasurer in the case o f a Town Council, saying "this cannot be done, it costs too much". On the other side we must then have the M.O.H. saying ,"All I tell you is that the health of the people is affected for the worse by this phenomenon, and that if this p h e n o m e n o n is reduced or removed it will no longer be so affected, over to you". if once the M.O.H. starts pulling his punches or softening his words because he knows there is a big expense involved, then the whole structure of decision making gets distorted. Dro C, D. L. Lyeett, Count)' Medical Officer, Wiltshire I do not think we should let the morning end without congratulating Lord Kennet on raising the question of noise. This is a subject which has been sparred with for m a n y years by Medical Officers o f Health and others who have tried to bring noise nuisance within the very a m o r p h o u s legislation on public health and c o m m o n law nuisances, and sparred with also by at least one Working Party. I would agree with Lord Kennet is suggesting that there is a degree of annoyance which can be called ill-health, from noise, but I would like to ask him how he would set about the problem of producing really workable, interpretable, and enforceable legislation on the subject. Lord Kennet This must be sector by sector. Let us make each successive generation o f aeroplane quieter than the one before. This is being done, or we are promised it is being done. There is the question fitting existing aircraft with quieter engines; I do not think any G o v e r n m e n t has bee~ br~ ve enough to enforce that yet but it could be done. So with cars.--imposing levels which ~ u s t be met by each successive generation o f cals and lorries on the roads.
278
PUBLIC HEALTH VOL. 85 NO. ~-,
Any Government will find it very much easier to do the right thing, and bring in tile right laws, if Medical Officers of Health in particular stand tip as one man and say "This you must do. Health is in danger".