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Health of the army in India
PUBLIC HEALTH theoretically at least, easier for what might be called the general purposes type of public health staff of the smaller authorities to correlate the special exigency of tuberculosis in a family with the social conditions which tend to make it a centre of not one but many public health problems. Dr. Lissant Cox touches on this difficulty in Wales, to which the Clement Davies Report devoted so much attention, and which has detracted from the value of an otherwise well designed scheme. He appears to be satisfied with the arrangements for interchange of information between the clinical and preventive staffs which obtain in some of the joint schemes he describes, but the mere transmission of information on paper does not ensure that a live interest will be taken in the remedy of domestic and social defects. An authority which has delegated the clinical care of tuberculosis to some other body does not readily provide senior staff with sufficient time, free from other duties, to ensure that the special environmental problems of tuberculosis receive due attention. It is this sort of difficulty in Wales, rather than any conscious or deliberate unwillingness to co-operate, which accounts for the state of affairs described in the Report of the Committee we have mentioned. The transfer of most health functions from the small district councils to county councils would be a step toward better things, but it would be better still if areas could be devised which would be suitable for the administration not only of tuberculosis schemes and of hospitals generally, but also of most other health services. The members of a common staff have obviously fewer bridges to cross in order to make contact with one another than those who are separately responsible to more or less independent masters. It should not be forgotten, however, that compartments within large departments are apt to become watertight. The claim that the care of tuberculosis is a specialism emphasises this danger. There can be no doubt that the creation of ad hoe organisations for the diagnosis and treatment of tuberculosis has led to a vast improvement in the detection of those who have been infected and in their subsequent care. There is evidence that a medical practitioner of average ability who concentrates on this disease, and has at his disposal all the facilities of a specialised organisation, will make far fewer mistakes than his opposite number who becomes a consulting physician. But there may be some justification for the crilicism, so often heard, that a doctor whose eye is filled with one disease is not the best consultant for the general practitioner, and it is even more difficult to answer the allegation that the great tuberculosis service of this country has made little contribution to original discovery. It may be that one of the greatest benefits of regionalisation would be to bring together hospital and other clinical staffs into a unity and promote a measure of fluidity within the unit which would counteract the sterilising effect of over-specialisation. If the public health service had not evolved in a piecemeal fashion, taking under its wing one disease, or one medical problem, or one group of the population at a time, its staffing might have taken a different form. But whatever may be the best arrangement from the clinical point of view, it is desir154
JUNE able that those who are actively concerned with the prevention of such diseases as tuberculofis in their daily work should not only be in contact with the clinicians but should themselves have sufficient practical knowledge of the disease to keep their activities on scientific lines. On the other hand, tuberculosis opens up so many other social problems that this function cannot be left solely to the specialist.
Health of the Army in India The Annual Report on the Health of the A r m y in India,* which formerly was issued by the Public Health Commissioner with the Government of India, now more fittingly comes from the D.M.S. in India himself. The present volume covers the year 1989, a period marked by the outbreak of war, and throughout its pages repeated references are made to the consequent increase in preventable disease. The unusual journeys, the early return of British troops to the plains from hill stations, the overcrowding of barracks, the manning of defensive posts scattered over unhealthy areas away from the protection of cantonment life, the drafting into cantonments of infected reservists, and the numbers of recruits infected before acceptance--aU these had an unfavourable influence on the Army's health. That was evidenced by a rise in hospital admission rates, which are described as higher than any recorded in recent quinquennial periods. But this state of affairs needs no apology ; an army would be of little use if it were confined to cantonments in order to keep its infectious diseases' incidence at a low level. It will, however, be interesting to compare the figures for 1940, when the next report is published, with those now under review. The Army Medical Services may be expected to have had time and opportunity to organise suitable preventive measures to meet the more difficult circumstances arising from the war. The present volume is divided into three sections, the first two dealing with British and Indian troop3 respectively. The third section of General W. H. Hamilton's report will be that to which most health offizers will turn, for it contains interesting and instructive paragraphs on different health problems and on modern methods of preventive medicine. Among both British and Indian troop~ malaria was as usual the commonest disease, although the dysenterydiarrhoea group also exacted a large toll of sickness. As regards the former, the D.M.S. pays a well-earned compliment to his trained and alert anti-malaria officers for their enthusiastic and skilled work in military cantonments. An equally deserved tribute is paid to the Malaria Institute of India and its staff for the valuable anti-malarial teaching courses given there. No one with any experience of India has any doubt of the immense debt which both military and civil authorities in India owe to the Malaria Institute. The three main anti-malarial methods practised in all cantonments are : (a) permanent drainage, (b) mosquito destruction in occupied premises, and (c) personal protection. As regards the elimination of the " carrier " mosquito, the usual well-tried methods are still in use, but recently it * Annual Report on the Health of the Army in India for the Year 1939. Vol. II, Part 1. Published by the Manager
of Publications, Delhi. Price 5s. 3d.
1941 has been found that breeding places can be effectively dealt with by spraying with pyrethrum solutions, the larvae being destroyed in a few seconds. Another innovation is the " dry-day," the introduction of which ensures that all potential breeding places in the cantonment are treated and that all the inhabitants sooner or later become acquainted with anti-malaria teaching. This bit of propaganda is said to have been very successful. Some years ago the Malaria Institute of India began investigations on the results to be obtained from destruction of adult mosquitoes in houses, barracks, etc., and it was found that pyrethrum spraying markedly reduced the incidence of malaria in the communities among which the experiments were carried out. This method is now widely practised in army cantonments and is used as a defence not only against mosquitoes but against other disease-bearing insects, with, it is said, effective results. A further and more recent development is the successful cultivation of the pyrethrum plant in Kashmir and other parts of India. As the Indian-grown plants contain an equally high percentage of the pyrethrin base, and the price will be considerably lower than that of the imported drug, it is expected that this preventive method will soon be much more widely applied. Atebrin has now been used for some considerable time in India-in the treatment of certain forms of malaria. An interesting paragraph gives preliminary results of the " anticipatory " treatment of malaria by atebrin and promises a final note later. It is hinted that the experiment was not very successful, and this is perhaps not altogether surprising. Sandfly fever has for many years been a veritable bugbear in a number of Indian military stations, and more than one research enquiry on this disease has been financed by the Indian Research Fund Association. The present war has necessitated the premature closing down of the latest investigation, but, although laboratory work on blood sera failed to produce results, the value of various anti-larval methods and of insecticidal spray solutions has been successfully demonstrated. In North India, particularly, very striking reductions have been effected in the incidence of sandfly fever since the spraying campaign was vigorously prosecuted. One of the most successful pieces of preventive work is that which has practically abolished enteric fever from both British and Indian troops in India. When it is remembered that this infection is almost ubiquitous in the civil population, it is surprising to learn that only one soldier in 2,000 was infected during the year under review. The claim is made that this result is unquestionably due to the high standard of protective immunisation with T.A.B. vaccine. The figures given in the report (even though there is a serious statistical error in the sentence following Table 69) will be of particular interest to health officers in this country at the present moment, when the question of inoculating certain groups of the population with T.A.B. vaccine is being actively discussed. Restrictions of space prevent comment on other important subjects, such as the prevalence of the diarrhoea-dysentery group of infections, the V.D. situation, the experiments in composting, the use of bore-hole latrines, and modern prevention against heat
PUBLIC HEALTH stroke and heat exhaustion. Much useful and interesting information is contained in the report, but owing to the somewhat unusual arrangement of its contents it is not so easy as it might be to find that information. One more word of advice may perhaps be added. If it is intended, as promised, to issue later on a volume of statistical tables as an appendix to this report, is it necessary to include so many figures in this first volume ? And in these days of paper shortage it can hardly be justifiable to waste space by repeating the same figures even though these appear on different pages.
Tuberculosis in Wartime In a symposium on tuberculosis in wartime* by Profe3sor Edgar.Collis, and Drs. Frederlck Heaf and Lloyd Rusby, Professor Collis writes on ' Tuberculosis and Influenza in Relation to the World War, 1914-18 " presumably because he thinks that the peculiar behaviour of these two diseases had a common cause. He says of the last war, " Its end coincided with the great and deadly influenza epidemic of the 1918-19 winter . . . . Had not the armistice intervened hostilities would almost certainly have been thereby closed down." With that personal opinion most of us would disagree. It is not indeed proven that that epidemic was a direct outcome of the war and would not have occurred otherwise. A single epidemiological experience, even on a vast scale, is not proof. When the present war burst upon us it was feared that there would be widespread epidemics as a result of dispersal of the population, and some severe late winter epidemics from the herding of eople in shelters. But neither prophecy has yet been lfilled. As to tuberculosis, Professor Collis, whose contribution is mainly statistical, states that if 100 be taken as the tuberculosis mortality for 1851-60, in 1981-85 the figure was reduced to 10, 26.9 and 82.6 for the agegroups 0-5, 9.0-25 and 45-55 respectively. It is said that the rise in mortality of 1918 " can only be attributed to deficient food supply," but this is qualified by the explanation that what is meant is a food supply which is deficient having regard to energy output. To one who moved among the working-class population at that time the food supply did not appear even relatively defective but better than before the war; it is possible that overwork and too little rest were more important predisposing factors. A chart comparing real wage3 with tuberculosis mortality suggests a definite relationship. Drs. Rusby and Heaf, reviewing the present position of tuberculosis, consider first the pre-war background and the various lines of research then in progress. They then come to " the period of anticipated bombhag," when tuberculosis organisation and staffs were disarrayed, a n d " the effort to return to normal services." The statement that " tuberculous or potentially tuberculous individuals could be excluded by mass radiography and in no other w a y " seems a little extreme, for already the method of reference to the tuberculosis officer has led to the discovery of large numbers of such recruits. No doubt mistakes do occur, but while mass *Tubercle,
August-September, 1940. 155
JUNE able that those who are actively concerned with the prevention of such diseases as tuberculofis in their daily work should not only be in contact with the clinicians but should themselves have sufficient practical knowledge of the disease to keep their activities on scientific lines. On the other hand, tuberculosis opens up so many other social problems that this function cannot be left solely to the specialist.
Health of the Army in India The Annual Report on the Health of the A r m y in India,* which formerly was issued by the Public Health Commissioner with the Government of India, now more fittingly comes from the D.M.S. in India himself. The present volume covers the year 1989, a period marked by the outbreak of war, and throughout its pages repeated references are made to the consequent increase in preventable disease. The unusual journeys, the early return of British troops to the plains from hill stations, the overcrowding of barracks, the manning of defensive posts scattered over unhealthy areas away from the protection of cantonment life, the drafting into cantonments of infected reservists, and the numbers of recruits infected before acceptance--aU these had an unfavourable influence on the Army's health. That was evidenced by a rise in hospital admission rates, which are described as higher than any recorded in recent quinquennial periods. But this state of affairs needs no apology ; an army would be of little use if it were confined to cantonments in order to keep its infectious diseases' incidence at a low level. It will, however, be interesting to compare the figures for 1940, when the next report is published, with those now under review. The Army Medical Services may be expected to have had time and opportunity to organise suitable preventive measures to meet the more difficult circumstances arising from the war. The present volume is divided into three sections, the first two dealing with British and Indian troop3 respectively. The third section of General W. H. Hamilton's report will be that to which most health offizers will turn, for it contains interesting and instructive paragraphs on different health problems and on modern methods of preventive medicine. Among both British and Indian troop~ malaria was as usual the commonest disease, although the dysenterydiarrhoea group also exacted a large toll of sickness. As regards the former, the D.M.S. pays a well-earned compliment to his trained and alert anti-malaria officers for their enthusiastic and skilled work in military cantonments. An equally deserved tribute is paid to the Malaria Institute of India and its staff for the valuable anti-malarial teaching courses given there. No one with any experience of India has any doubt of the immense debt which both military and civil authorities in India owe to the Malaria Institute. The three main anti-malarial methods practised in all cantonments are : (a) permanent drainage, (b) mosquito destruction in occupied premises, and (c) personal protection. As regards the elimination of the " carrier " mosquito, the usual well-tried methods are still in use, but recently it * Annual Report on the Health of the Army in India for the Year 1939. Vol. II, Part 1. Published by the Manager
of Publications, Delhi. Price 5s. 3d.
1941 has been found that breeding places can be effectively dealt with by spraying with pyrethrum solutions, the larvae being destroyed in a few seconds. Another innovation is the " dry-day," the introduction of which ensures that all potential breeding places in the cantonment are treated and that all the inhabitants sooner or later become acquainted with anti-malaria teaching. This bit of propaganda is said to have been very successful. Some years ago the Malaria Institute of India began investigations on the results to be obtained from destruction of adult mosquitoes in houses, barracks, etc., and it was found that pyrethrum spraying markedly reduced the incidence of malaria in the communities among which the experiments were carried out. This method is now widely practised in army cantonments and is used as a defence not only against mosquitoes but against other disease-bearing insects, with, it is said, effective results. A further and more recent development is the successful cultivation of the pyrethrum plant in Kashmir and other parts of India. As the Indian-grown plants contain an equally high percentage of the pyrethrin base, and the price will be considerably lower than that of the imported drug, it is expected that this preventive method will soon be much more widely applied. Atebrin has now been used for some considerable time in India-in the treatment of certain forms of malaria. An interesting paragraph gives preliminary results of the " anticipatory " treatment of malaria by atebrin and promises a final note later. It is hinted that the experiment was not very successful, and this is perhaps not altogether surprising. Sandfly fever has for many years been a veritable bugbear in a number of Indian military stations, and more than one research enquiry on this disease has been financed by the Indian Research Fund Association. The present war has necessitated the premature closing down of the latest investigation, but, although laboratory work on blood sera failed to produce results, the value of various anti-larval methods and of insecticidal spray solutions has been successfully demonstrated. In North India, particularly, very striking reductions have been effected in the incidence of sandfly fever since the spraying campaign was vigorously prosecuted. One of the most successful pieces of preventive work is that which has practically abolished enteric fever from both British and Indian troops in India. When it is remembered that this infection is almost ubiquitous in the civil population, it is surprising to learn that only one soldier in 2,000 was infected during the year under review. The claim is made that this result is unquestionably due to the high standard of protective immunisation with T.A.B. vaccine. The figures given in the report (even though there is a serious statistical error in the sentence following Table 69) will be of particular interest to health officers in this country at the present moment, when the question of inoculating certain groups of the population with T.A.B. vaccine is being actively discussed. Restrictions of space prevent comment on other important subjects, such as the prevalence of the diarrhoea-dysentery group of infections, the V.D. situation, the experiments in composting, the use of bore-hole latrines, and modern prevention against heat
PUBLIC HEALTH stroke and heat exhaustion. Much useful and interesting information is contained in the report, but owing to the somewhat unusual arrangement of its contents it is not so easy as it might be to find that information. One more word of advice may perhaps be added. If it is intended, as promised, to issue later on a volume of statistical tables as an appendix to this report, is it necessary to include so many figures in this first volume ? And in these days of paper shortage it can hardly be justifiable to waste space by repeating the same figures even though these appear on different pages.
Tuberculosis in Wartime In a symposium on tuberculosis in wartime* by Profe3sor Edgar.Collis, and Drs. Frederlck Heaf and Lloyd Rusby, Professor Collis writes on ' Tuberculosis and Influenza in Relation to the World War, 1914-18 " presumably because he thinks that the peculiar behaviour of these two diseases had a common cause. He says of the last war, " Its end coincided with the great and deadly influenza epidemic of the 1918-19 winter . . . . Had not the armistice intervened hostilities would almost certainly have been thereby closed down." With that personal opinion most of us would disagree. It is not indeed proven that that epidemic was a direct outcome of the war and would not have occurred otherwise. A single epidemiological experience, even on a vast scale, is not proof. When the present war burst upon us it was feared that there would be widespread epidemics as a result of dispersal of the population, and some severe late winter epidemics from the herding of eople in shelters. But neither prophecy has yet been lfilled. As to tuberculosis, Professor Collis, whose contribution is mainly statistical, states that if 100 be taken as the tuberculosis mortality for 1851-60, in 1981-85 the figure was reduced to 10, 26.9 and 82.6 for the agegroups 0-5, 9.0-25 and 45-55 respectively. It is said that the rise in mortality of 1918 " can only be attributed to deficient food supply," but this is qualified by the explanation that what is meant is a food supply which is deficient having regard to energy output. To one who moved among the working-class population at that time the food supply did not appear even relatively defective but better than before the war; it is possible that overwork and too little rest were more important predisposing factors. A chart comparing real wage3 with tuberculosis mortality suggests a definite relationship. Drs. Rusby and Heaf, reviewing the present position of tuberculosis, consider first the pre-war background and the various lines of research then in progress. They then come to " the period of anticipated bombhag," when tuberculosis organisation and staffs were disarrayed, a n d " the effort to return to normal services." The statement that " tuberculous or potentially tuberculous individuals could be excluded by mass radiography and in no other w a y " seems a little extreme, for already the method of reference to the tuberculosis officer has led to the discovery of large numbers of such recruits. No doubt mistakes do occur, but while mass *Tubercle,
August-September, 1940. 155