- Email: [email protected]
International discussions on V.D.
PUBLIC H E A L T H , J a n u a r y , 1948
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boiled in soda, upon w h i c h a large part of pre-war E n g l i s h people fed; the rats became rapidly ill a n d fell to e a t i n g each other. The N o r t h e r n i n d i a n races' m a i n diet consisted of "' whole meal flour, milk, butter, vegetables a n d fruit," t h e same as t h a t w h i c h Sir Jack D r u m m o n d n a s shown to be the " s i m p l e diet of the 18th c e n t u r y p e a s a n t " a n d not unlike t h e " c o a r s e whole g r a i n bread, thick vegetable stews a n d goats' milk cheese " t h a t prevailed before the war in south-eastern Europe, or t h a t f a m o u s meal w h i c h Professor Schiotz introduced as a b r e a k f a s t for Oslo school children, namely, " whole meal rolls, butter or vitaminised m a r g a r i n e , milk, cheese a n d raw fruit or salad." These various diets h a d no other m a g i c t h a n a h i g h c o n t e n t of essential n u t r i e n t s ; a h i g h biological protein value by m i x t u r e of milk, or milk cheese, a n d flour; v i t a m i n s A a n d D in the b u t t e r ; v i t a m i n C in the fruits a n d s a l a d ; v i t a m i n B group in the unextracted flour; a good supply of c a l c i u m in t h e milk a n d other inorganic elements m the fruits a n d t h e whole wheat. Yet their virtues remained largely u n a p p r e c i a t e d in E n g l a n d r i g h t up to the outbreak of the war. Some of t h e ingredients also were too expensive for general u s e ; Sir J o h n Orr records that, at Aberdeen prices in 1940, the cost Of 2,500 calories o b t a i n e d f r o m different sources was as follows: white bread, 4½d. ; milk, Is. 8d. ; vegetables, 2s. 7d. ; a n d eggs, 5s. 1¼d., a n d t h u s tt is not surprising that in the diet of the poor m o s t of the essential n u t r i e n t s were reduced to a half or even a third of t h a t of the rich. T h e wellto-do added milk, butter a n d cheese to their diet a n d ate larger quantities of meat, so t h a t there was a considerable difference in pre-war E n g l a n d between the diet of t h e rich a n d t h e poor, who were more usually t h e families with children not y e t earning. An a t t e m p t to redress the balance b e g a n before the recent war when milk at reduced prices a n d m i d d a y meals were first m a d e available in schools, b u t it was t h e war w h i c h produced a great advance in the practical application of t h e principle of feeding according to biological needs. W i t h t h e war c a m e rationing, stabilisation of food prices b y subsidies,* a compulsory flour of lower extraction, a vast extension of school meals a n d milk schemes, and the priority system of distribution. T h e effects of these steps have been far-reaching. W e do not live to-day as simply as the 18th century p e a s a n t or a Balkan shepherd, b u t there are m a n y millions in E n g l a n d now whose diet is as far removed f r o m t h a t on which t h e y lived before the war as McCarrison detected between the diets of n o r t h e r n a n d s o u t h e r n Indians. The remarkable changes in vital statistics, particularly of our m o t h e r s a n d children, must be Iargely ascribed to t h e success of this great biological experiment. T h e effect of the c h a n g e s h a s been of particular importance to t h e growing family. A n i m a l proteins~ particularly milk, cheese a n d eggs, a n d to a lesser extent m e a t a n d fish, are expensive, a n d the d a n g e r always exists t h a t t h e y m a y be squeezed out of the family diet when t h e income is insufficient for all purposes. Certainly the a m o u n t of a n i m a l protein foods decreased in W e s t Sussex families in 1937 as the f a m i l y got bigger a n d the rate of growth of t h e children in these families declined in proportion. T h e f u r t h e r development of this u n f o r t u n a t e t r e n d h a s been checked a n d the situation, u n d o u b t e d l y a l a r m i n g , h a s been largely remedied b y t h e s c h e m e s of priority distribution w h i c h have come into operation since then. Meals were given in schools before t h e war to only 5% of t h e total c h i l d r e n ; 42% received a meal in 1946. T h e n u m b e r of children receiving milk at school has risen from 55% in 1939 to 71.7% in 1946 and, f u r t h e r m o r e , the q u a n t i t y c o n s u m e d at school h a s doubled. T h e school meal, which should contain 25 g r a m m e s of first-class protein (Circular 1571/1941), a n d the third of a pint of milk, w h i c h gives 4½ g r a m m e s , together have done m u c h to secure a satisfactory protein intake. How different t h e protein intake of t h e average school c h i l d to-day {tom t h a t in 1926 when Corry M a n n pointed t h e way to this notable a c h i e v e m e n t in social medicine. F u r t h e r m o r e , with increasing p u r c h a s i n g power the priority allowance of h a l f a pint of milk for children over six h a s been s u b s t a n t i a l l y drunk. By t h e end of 1943 families in Stoke-on-Trent a n d Salford were shown to be b u y i n g t h e full a m o u n t of milk a n d to go on b u y i n g it ( a l t h o u g h meat, fish a n d other t h i n g s declined) even when the n u m b e r of children in t h e f a m i l y i n c r e a s e d ; this is a notable c h a n g e a n d in marked contrast with the findings in W e s t Sussex six years previously. Milk c o n s u m e d in this c o u n t r y is appreciably g r e a t e r t than before the war a n d h a l f of it is now t a k e n b y t h e priority classes who, b e i n g b u t twelve millions, constitute only a b o u t a quarter of the population. * T h e s e have risen steadily from 63.1 millions in 1940-41 to 392 millions in 1946-47, e x c l u d i n g a d m i n i s t r a t i v e a n d publicity COSTS.
t T h e W h i t e Paper of September, 1947, increase in c o n s u m p t i o n of l i q u i d milk, a achieved to some extent b y a fall-off in products. Total dairy products, e x c l u d i n g above pre-war.
gave a figure of figure which h a s cheese a n d other butter, stood at
44% been milk 30 °/ ,o
]f this is a true picture of t h e situation generally t h r o u g h o u t the c o u n t r y t h e n most certalnly there h a s been a revolution in our c h i l d r e n ' s diets. It is salutary to recall t h a t t h e c o n s u m p t i o n of m i l k per h e a d of 205 families in t h e W e s t R i d i n g o f Yorkshire in 1939 averaged less t h a n a. q u a r t a week a n d t h a t in Newcastleo n - T y n e in 1940 u n e m p l o y e d families were receiving less t h a n h a l f a pint per h e a d per week. H a b i t s of feeding in E n g l a n d have been rudely s h a k e n a n d drastically altered in t h e course of a comparatively short time, a n d it is therefore perhaps n a t u r a l that there should be m a n y who seek to show t h a t s u c h great c h a n g e s spell disaster. If we are h o n e s t we c a n n o t claim to know with certainty w h e t h e r this f o r e b o d i n g contains a n y t r u t h or is b u t the evidence of querulousness of those who dislike c h a n g e s in long a c c u s t o m e d habits. It does not accord with the evidence of dietary surveys nor with t h e known facts of our physical state, both of w h i c h suggest r a t h e r t h a t the scientific feeding of t h e British people h a s been b r o u g h t to a h i g h standard. N e i t h e r does it accord with t h e evidence of t h e W h i t e Paper ( C o m m a n d 7203, 1947) w h i c h leaves little doubt t h a t t h e average person is fed according to physiological requirements. T h e r e is now ~robably m o r e e q u a l i t y of feeding in E n g l a n d t h a n ever before i n ' t h i s or a n y other country. Millions are better fed t h a n for perhaps 100 to 200 years ; some t h o u s a n d s h a v e not their former a b u n d a n c e . W e know with some certainty t h a t t h e millions have benefited. As to t h e few, we do not know w h e t h e r they are better or worse for t h e change. I am, Sir, Yours, etc., SEARCHER AFTER TRUTH.
INTERNATIONAL DISCUSSIONS ON V.D. T h e four questions of o u t s t a n d i n g interest raised at t h e first General A s s e m b l y of t h e U n i o n Internationale Contre le P6ril V6n6rien since 1939, held recently in Paris, were (I) the use (and abuse) of penicillin ; (2) t h e possibility of an international arrangem e n t for t h e prevention of t h e spread of disease a n d t h e adequate t r e a t m e n t of t h e infected t h a t would include a n d improve the provisions of t h e Brussels A g r e e m e n t for seafarers, a n d would provide for t h e needs of m i g r a n t s a n d displaced p e r s o n s ; (3) the recidivist of b o t h sexes a m o n g V.D. p a t i e n t s ; a n d (4) t h e place of the general practitioner in t h e fight against venereal disease. In spite of difficult conditions in Paris owing to the strike at t h e e n d of October, several representatives from e a c h of 15 nations a n d f r o m f o u r international organisations attended. D u r i n g the past year the U n i o n h a s established a Regional office with t h e aid of a financial contribution a n d loan of staff f r o m t h e A m e r i c a n Social H y g i e n e Association. Its activities have included a tour t h r o u g h the South A m e r i c a n Republics by M. Fleursheim, Hon. T r e a s u r e r of t h e Union. Dr. W i l l i a m Snow, Hon. Director of t h e A m e r i c a n Social H y g i e n e Association a n d a m e m b e r of the Consultative C o m m i t t e e of the Federal G o v e r n m e n t H e a l t h D e p a r t m e n t , presided over the meetings as t h e newly elected President of t h e Union. France anti Italy were represented b y t h e Secretaries of their H e a l t h Departments. Dr. Heller, Chief of the U.S.A. Federal V.D. D e p a r t m e n t , attended as one of t h e A m e r i c a n delegation a n d was elected a T e c h n i c a l Adviser. T h e R u s s i a n delegatiorr of p r o m i n e n t venereologists were u n f o r t u n a t e l y delayed a n d a r r i v e d after t h e final a n d plenary Session. T h e F r e n c h Reception C o m m i t t e e h a d planned to show the delegates t h e f u n c t i o n i n g of their V.D. s c h e m e in t h e devastated areas a n d in seaports b y a r r a n g i n g a two-day motor coach tour t h r o u g h Rouen, Havre, Honfieur a n d Caen. Generous hospitality was accorded by t h e civic a n d medical authorities at each stopping place. Dr. F o r g a n represented the Central Council for H e a l t h E d u c a t i o n as official British delegate, a n d Colonel L. W. Harrison, c.B., Technical Adviser f r o m t h e Ministry of H e a l t h , and Mrs. Neville-Rolfe, O.B.E., Vice-President of the Union, also attended. T h e discussion on penicillin showed a m u c h more conservati~'e attitude towards its use for V?.D. a m o n g the F r e n c h dermatologists t h a n in t h e U.S.A. a n d Great Britain. M a n y countries h a d n o t h a d a sufficient supply for it to be in general use at the V.D. clinics. Of great interest was Dr. Heller's account of the rapidly developed quick t r e a t m e n t centres in t h e U.S.A. t h r o u g h w h i c h some 180,000 patients pass per a n n u m . T h e prevalence of recidivism h a d been t h r o w n into relief, a n u m b e r of patients of b o t h sexes h a v i n g reappeared four times within t h e year with new infections. T h e question of relapse was raised, b u t Dr. Heller m a i n t a i n e d t h e two conditions were clearly distinguishable. T h e h a r m arising from the issue of penicillin in tablet f o r m a n d its irresponsible use by t h e public, was r e n d e r i n g it useless in m a n y cases as a cure for serious conditions. T h e F r e n c h were p a r t i o i larly insistent on this point a n d a resolution was passed d r a w i n g the attention of all medical a u t h o r i t i e s to t h e danger.
PUBLIC H E A L T H , J a n u a r y , 1948
68 A lively discussion was based on t h e papers f r o m fonr countries (of w h i c h Colonel H a r r i s o n c o n t r i b u t e d one) on t h e part the general p r a c t i t m n e r s can play in the fight a g a i n s t V.D. All were u n a n i m o u s t h a t their coroperation was essential, b u t h i t h e r t o their assistance in contact t r a c i n g h a d n o t been f o r t h c o m i n g a n d in m o s t countries their co-operation with t h e clinic medical staffs was not close. Dr. F o r g a n aroused considerable interest in describing the E d i n b u r g h s c h e m e where co-operation Over a wide area h a s worked successfully for some years. T h e time involved in contact tracing a n d preventive m e a s u r e s was recognised, a n d a resolution u r g i n g t h a t t i m e so spent s h o u l d be p a i a for by t h e h e a l t h a u t h o n t i e s was a d o p t e d for circulation to governments. T h e question of t h e Brussels A g r e e m e n t , its a m e n d m e n t a n d the revival of the Ports C o m m i s s i o n by the U n i o n was raised by Mrs. Nevitle-Rolfe. Dr. Guthe, Secretary of t h e V.D. Sub-committee of t h e I n t e r i m C o m m i s s i o n of W.H.O., outlined t h e present position of t h e Brussels A g r e e m e n t a n d indicated t h a t its revision would involve a two years' process t h r o u g h diplomatic c h a n n e l s while its r e p l a c e m e n t b y W.H.O. regulations would become effective forthwith. T h e U n i o n , at their Council m e e t i n g in May, h a d already raised the need for some similar m e a s u r e s to meet t h e needs of m i g r a n t s a n d to enable t h e infected to be traced across frontiers. T h e I n t e r i m C o m m i s s i o n h a d appointed t h e V.D. C o m m i t t e e to s t u d y t h e possible scope of a n I n t e r n a t i o n a l V.D. a r r a n g e m e n t covering b o t h aspects of t h e question, seafarers a n d m i g r a n t s . Delegates f r o m several countries cited t h e additional difficulties-that arose f r o m large bodies of alien labour a n d displaced persons living in c a m p s t h r o u g h o u t Europe. T h e s e persons faced social c o n d i u o n s as d a n g e r o u s to h e a l t h as those of t h e seafarer before t h e m o v e m e n t to improve port conditions a n d provide treatment. T h o u s a n d s of m e n were separated f r o m their h o m e s a n d families while recreative facilities a n d amenities were u s u a l l y quite inadequate: T h e U n i o n set up a C o m m i t t e e u n d e r t h e c h a i r m a n s h i p of Dr. H e r m a n s of Holland, c h a r g e d with t h e d u t y of s t u d y i n g b o t h aspects of t h e problem. T h e C o m m i t t e e would work in two parts where t h e interests of t h e seafarer a n d t h e m i g r a n t diverged so t h a t p l a n s for b o t h should be prepared. It was fully recognised t h a t all special provisions, s u c h as dockside clinics a n d port welfare, s h o u l d be preserved in a n y wider m e a s u r e for t h e intern a t i o n a l prevention a n d t r e a t m e n t of V.D. T h e U n i o n have asked W.H.O. to assist t h e m financially in c o n v e n i n g a n International V o l u n t a r y Conference in the c o m i n g , m o n t h s to w h i c h N a t i o n a l bodies a n d experts can be invited. T h e need for collecting opinions a n d experience f r o m as wide a field as possible, so t h a t alI available i n f o r m a t i o n a n d ideas can reach t h e W.H.O. while the m a t t e r is u n d e r discussion, was appreciated. It was i n f o r m a l l y suggested t h a t t h e delegates of each m a r i t i m e c o n n t r y s h o u l d e n d e a v o u r to p r o m o t e a N a t i o n a l V o l u n t a r y Conference of all concerned with t h e Brussels A g r e e m e n t and with m i g r a n t s a n d alien labour, from w h i c h a delegation could be appointed to t h e I n t e r n a t i o n a l Voluntary C o n f e r e n c e . W h i l e g o v e r n m e n t s can provide statistical returns a n d official reports, it was held t h a t m a n y points would be raised b y i n d i v i d u a l s of experience a n d non-official bodies at s n c h conferences, w h i c h could n o t find a place in t h e g o v e r n m e n t statements. Mrs. Neville-Rolfe's report on Sex B e h a v i o u r a n d Venereal Disease was t h e basis of a lively discussion. It was agreed u n a n i m o u s l y to adopt t h e suggestion t h a t a Study C o m m i t t e e should be appointed of w h i c h she was elected C h a i r m a n . M a n y offers were m a d e to participate in a n international e n q u i r y t h r o u g h t h e clinics a n d their social services into the b a c k g r o u n d of the recidivist. T h e second item referred for e n q u i r y was t h e type of biological t e a c h i n g related to h u m a n affairs a n d t h e content of sex g u i d a n c e related to the fatflily t h a t was b e i n g given in each country. In this e n q u i r y the co-operation a n d advice of U.N.E.S.C.O. is to be sought.
Askwith Agreement~Second Interim Revision.--For t h e information of m e m b e r s , t h e position is t h a t all t h e bodies concerned, except t h e L,C.C,, have now confirmed t h e r e c o m m e n d a t i o n s of t h e conference held at t h e M i n i s t r y of H e a l t h on J u l y 28th last. T h e formal confirmation of t h e L.C.C. is expected shortly, w h e r e u p o n the M i n i s t r y will circulate t h e d o c u m e n t to all local authorities. T h e new percentage increases will be applicable f r o m J u l y 1st last. New Year Honours.~We congratulate two m e m b e r s of t h e Society whose n a m e s a p p e a r e d in t h e list, viz., Lieut.-General T. O. T h o m p s o n (until recently Director of Medical Services, India) who becomes K n i g h t - C o m m a n d e r , Order of t h e Star of India, a n d Dr. Victoria M a r y Crosse (Dep. Sen. A.M.O.H., B i r m i n g h a m ) who receives the Order of t h e British Empire. A d v e r t i s e m e n t s of appointments, courses, etc., appear on p. vii, f a c i n g p. 72.
SOCIETY
OF
MEDICAL
OFFICERS
OF H E A L T H
COUNCIL MEETING A m e e t i n g of t h e Council was held in t h e H a s t i n g s Hall, Tavistock House, L o n d o n , W.C.I, on Friday, N o v e m b e r 28th, 1947, at 10 a.m. T h e r e were present t h e C h a i r m a n of Council (Dr. G. F. Buchan), the President (Dr. F. Hall) a n d Drs. Cyril Banks, Fraser Brockington, G. L. Brocklehurst, C. Metcalfe Brown, H. A. B u l m a n , H. D. Chalke, W. G. Clark, C. K. Cullen, Sir Allen Daley, Dr. R. H. G. Hector D e n h a m , Sir George Elliston, Dr. M i r i a m Florentin, Prof. W. M. Frazer, Drs. R. M. Galloway, J. M. Gibson, F. Gray, A. S. Hebblethwaite, C. Herington, K a t h e r i n e Hirst, Sir W i l s o n J a m e s o n , Prof. J. J o h n s t o n e Jervis, Drs. R. H. H. Jolly, R. A. Leader, ProL J. M. M a c k i n t o s h , Drs. J o h n Maddison, A. Morrison, A. A. E. Newth, H. L. Oldershaw, W y n d h a m Parker, Prof. R. H. Parry, Drs. H. Paul, D. D. Payne, Prof. R, M. F. Picken~ Dr. T. RuddockWest, J. E. Spence, Mr. A. Gordon Taylor, Drs. N o r a Wattle, H. C. M a u r i c e W i l l i a m s a n d F. T. I-t; Wood. Apologies for absence were received from Drs. Jas. Fenton, J. A. Stirling a n d J. A. Struthers. T h e C h a i r m a n welcomed Drs. H. L. Oldershaw a n d J. E. Spence on their r e t u r n to t h e Council after an interval a n d t h e following new m e m b e r s who were a t t e n d i n g their first m e e t i n g : Drs. G. L. Brocklehurst, H. D. Chalke, R. H. G. Hector D e n h a m , D. D. P a y n e a n d T. R u d d o e k - W e s t . Election o[ Departmental Officers under Article 19 ( d ) . - - T h e folIowiug were elected on t h e n o m i n a t i o n of t h e Inter-Group Committee: Drs. M i r i a m F l o r e n t i n a n d A. Morrison, a n d Mr, J. v . Bingay, Ln.s. Minutes of t h e m e e t i n g h e l d on September 19th, p u b l i s h e d in PUBLic HEaLTg, October, p. 14, were confirmed a n d signed b y t h e Chairman. Report of the General Purposes Committee.--Dr. J. M. Gibson (Chairman) presented t h e report a n d , r e c o m m e n d a t i o n s of t h e General Purposes C o m m i t t e e (see page 73). T h e s e were adopted with t h e following a d d i t i o n s a n d m o d i f i c a t i o n s : - Min. 73.--Salaries.--Dr. B u c h a n reported t h a t t h e B.M.A. representatives h a d visited the Minister of H e a l t h on O c t o b e r 28th a n d h a d i n f o r m e d t h e Minister t h a t there was objection to a proposal of a central council, c o n t a i n i n g n o n - m e d i c a l elements on the employees' side, w h i c h would have t h e last word in r e g a r d to t h e a m o u n t a n d conditions of m e d i c a l pay. Dr. W. G. Clark pointed o u t t h a t in Scotland t h e proposed W h i t l e y m a c h i n e r y excluded local a u t h o r i t y representatives on a c c o u n t of t h e latter's refusal to enter t h e scheme. He u r g e d t h a t t h e difference in t h e Scottish A c t m u s t be recognised. In t h e past Scottish public h e a l t h medical officers h a d suffered f r o m b e i n g o u t w i t h t h e A s k w i t h m a c h i n e r y . Min. 77.--Cremation Regulations.--As a result of discussion on t h e proposal b y Drs. B a n k s a n d W h i t e for t h e complete omission of t h e present F o r m C, it was decided to m o d i f y this r e c o m m e n d a t i o n so as to leave power for t h e referee to require a confirmatory certificate in cases where he considered this necessary, a n d t o give h i m the r i g h t of selecting t h e practitioner to complete F o r m C. R e g a r d i n g oral evidence it was agreed t h a t Dr. B a n k s s h o u l d be n o m i n a t e d .
Min. 78.--Superintendent Nursing Officers and Health Visitors.--The Council considered c o m m e n t s f r o m t h e M. & C.W. .Group on t h e Royal College of N u r s i n g m e m o r a n d u m regardm g t h e duties a n d conditions of service of s u p e r i n t e n d e n t h e a l t h visitors a n d correspondence between t h e W o m e n Public H e a l t h Officers Association a n d t h e M i n i s t r y of H e a l t h regardi n g the a p p o i n t m e n t s of s u p e r i n t e n d i n g n u r s i n g officers suggested in t h e M i n i s t r y ' s Circular 118/47, para. 27. The Council opinion : - -
adopted .. t h e
following
expressions
of
(a) T h e r e are very few people who would be qualified at one a n d t h e s a m e time to s u p e r i n t e n d I t e a l t h Visitors, Domiciliary Midwives a n d District Nurses. (b) S u p e r i n t e n d e n t H e a l t h Visitors a n d Supervisors of Midwives at t h e present time work a m i c a b l y on an equal footing, w i t h o u t t h e i n t e r v e n t i o n of a Superintendent N u r s i n g Officer. (c) T h e three different services are such t h a t t h e y c a n n o t be " r o l l e d " into one, a n d t h e Medical Officer of H e a l t h is t h e only person to co-ordinate these duties.
Min. 80.--Sanitary Provision by Railway Companies.--Agreei n g the action proposed b y t h e Committee, the Council decided to ask t h e M i n i s r y of H e a l t h to encourage t h e o b t a i n i n g of
67
boiled in soda, upon w h i c h a large part of pre-war E n g l i s h people fed; the rats became rapidly ill a n d fell to e a t i n g each other. The N o r t h e r n i n d i a n races' m a i n diet consisted of "' whole meal flour, milk, butter, vegetables a n d fruit," t h e same as t h a t w h i c h Sir Jack D r u m m o n d n a s shown to be the " s i m p l e diet of the 18th c e n t u r y p e a s a n t " a n d not unlike t h e " c o a r s e whole g r a i n bread, thick vegetable stews a n d goats' milk cheese " t h a t prevailed before the war in south-eastern Europe, or t h a t f a m o u s meal w h i c h Professor Schiotz introduced as a b r e a k f a s t for Oslo school children, namely, " whole meal rolls, butter or vitaminised m a r g a r i n e , milk, cheese a n d raw fruit or salad." These various diets h a d no other m a g i c t h a n a h i g h c o n t e n t of essential n u t r i e n t s ; a h i g h biological protein value by m i x t u r e of milk, or milk cheese, a n d flour; v i t a m i n s A a n d D in the b u t t e r ; v i t a m i n C in the fruits a n d s a l a d ; v i t a m i n B group in the unextracted flour; a good supply of c a l c i u m in t h e milk a n d other inorganic elements m the fruits a n d t h e whole wheat. Yet their virtues remained largely u n a p p r e c i a t e d in E n g l a n d r i g h t up to the outbreak of the war. Some of t h e ingredients also were too expensive for general u s e ; Sir J o h n Orr records that, at Aberdeen prices in 1940, the cost Of 2,500 calories o b t a i n e d f r o m different sources was as follows: white bread, 4½d. ; milk, Is. 8d. ; vegetables, 2s. 7d. ; a n d eggs, 5s. 1¼d., a n d t h u s tt is not surprising that in the diet of the poor m o s t of the essential n u t r i e n t s were reduced to a half or even a third of t h a t of the rich. T h e wellto-do added milk, butter a n d cheese to their diet a n d ate larger quantities of meat, so t h a t there was a considerable difference in pre-war E n g l a n d between the diet of t h e rich a n d t h e poor, who were more usually t h e families with children not y e t earning. An a t t e m p t to redress the balance b e g a n before the recent war when milk at reduced prices a n d m i d d a y meals were first m a d e available in schools, b u t it was t h e war w h i c h produced a great advance in the practical application of t h e principle of feeding according to biological needs. W i t h t h e war c a m e rationing, stabilisation of food prices b y subsidies,* a compulsory flour of lower extraction, a vast extension of school meals a n d milk schemes, and the priority system of distribution. T h e effects of these steps have been far-reaching. W e do not live to-day as simply as the 18th century p e a s a n t or a Balkan shepherd, b u t there are m a n y millions in E n g l a n d now whose diet is as far removed f r o m t h a t on which t h e y lived before the war as McCarrison detected between the diets of n o r t h e r n a n d s o u t h e r n Indians. The remarkable changes in vital statistics, particularly of our m o t h e r s a n d children, must be Iargely ascribed to t h e success of this great biological experiment. T h e effect of the c h a n g e s h a s been of particular importance to t h e growing family. A n i m a l proteins~ particularly milk, cheese a n d eggs, a n d to a lesser extent m e a t a n d fish, are expensive, a n d the d a n g e r always exists t h a t t h e y m a y be squeezed out of the family diet when t h e income is insufficient for all purposes. Certainly the a m o u n t of a n i m a l protein foods decreased in W e s t Sussex families in 1937 as the f a m i l y got bigger a n d the rate of growth of t h e children in these families declined in proportion. T h e f u r t h e r development of this u n f o r t u n a t e t r e n d h a s been checked a n d the situation, u n d o u b t e d l y a l a r m i n g , h a s been largely remedied b y t h e s c h e m e s of priority distribution w h i c h have come into operation since then. Meals were given in schools before t h e war to only 5% of t h e total c h i l d r e n ; 42% received a meal in 1946. T h e n u m b e r of children receiving milk at school has risen from 55% in 1939 to 71.7% in 1946 and, f u r t h e r m o r e , the q u a n t i t y c o n s u m e d at school h a s doubled. T h e school meal, which should contain 25 g r a m m e s of first-class protein (Circular 1571/1941), a n d the third of a pint of milk, w h i c h gives 4½ g r a m m e s , together have done m u c h to secure a satisfactory protein intake. How different t h e protein intake of t h e average school c h i l d to-day {tom t h a t in 1926 when Corry M a n n pointed t h e way to this notable a c h i e v e m e n t in social medicine. F u r t h e r m o r e , with increasing p u r c h a s i n g power the priority allowance of h a l f a pint of milk for children over six h a s been s u b s t a n t i a l l y drunk. By t h e end of 1943 families in Stoke-on-Trent a n d Salford were shown to be b u y i n g t h e full a m o u n t of milk a n d to go on b u y i n g it ( a l t h o u g h meat, fish a n d other t h i n g s declined) even when the n u m b e r of children in t h e f a m i l y i n c r e a s e d ; this is a notable c h a n g e a n d in marked contrast with the findings in W e s t Sussex six years previously. Milk c o n s u m e d in this c o u n t r y is appreciably g r e a t e r t than before the war a n d h a l f of it is now t a k e n b y t h e priority classes who, b e i n g b u t twelve millions, constitute only a b o u t a quarter of the population. * T h e s e have risen steadily from 63.1 millions in 1940-41 to 392 millions in 1946-47, e x c l u d i n g a d m i n i s t r a t i v e a n d publicity COSTS.
t T h e W h i t e Paper of September, 1947, increase in c o n s u m p t i o n of l i q u i d milk, a achieved to some extent b y a fall-off in products. Total dairy products, e x c l u d i n g above pre-war.
gave a figure of figure which h a s cheese a n d other butter, stood at
44% been milk 30 °/ ,o
]f this is a true picture of t h e situation generally t h r o u g h o u t the c o u n t r y t h e n most certalnly there h a s been a revolution in our c h i l d r e n ' s diets. It is salutary to recall t h a t t h e c o n s u m p t i o n of m i l k per h e a d of 205 families in t h e W e s t R i d i n g o f Yorkshire in 1939 averaged less t h a n a. q u a r t a week a n d t h a t in Newcastleo n - T y n e in 1940 u n e m p l o y e d families were receiving less t h a n h a l f a pint per h e a d per week. H a b i t s of feeding in E n g l a n d have been rudely s h a k e n a n d drastically altered in t h e course of a comparatively short time, a n d it is therefore perhaps n a t u r a l that there should be m a n y who seek to show t h a t s u c h great c h a n g e s spell disaster. If we are h o n e s t we c a n n o t claim to know with certainty w h e t h e r this f o r e b o d i n g contains a n y t r u t h or is b u t the evidence of querulousness of those who dislike c h a n g e s in long a c c u s t o m e d habits. It does not accord with the evidence of dietary surveys nor with t h e known facts of our physical state, both of w h i c h suggest r a t h e r t h a t the scientific feeding of t h e British people h a s been b r o u g h t to a h i g h standard. N e i t h e r does it accord with t h e evidence of t h e W h i t e Paper ( C o m m a n d 7203, 1947) w h i c h leaves little doubt t h a t t h e average person is fed according to physiological requirements. T h e r e is now ~robably m o r e e q u a l i t y of feeding in E n g l a n d t h a n ever before i n ' t h i s or a n y other country. Millions are better fed t h a n for perhaps 100 to 200 years ; some t h o u s a n d s h a v e not their former a b u n d a n c e . W e know with some certainty t h a t t h e millions have benefited. As to t h e few, we do not know w h e t h e r they are better or worse for t h e change. I am, Sir, Yours, etc., SEARCHER AFTER TRUTH.
INTERNATIONAL DISCUSSIONS ON V.D. T h e four questions of o u t s t a n d i n g interest raised at t h e first General A s s e m b l y of t h e U n i o n Internationale Contre le P6ril V6n6rien since 1939, held recently in Paris, were (I) the use (and abuse) of penicillin ; (2) t h e possibility of an international arrangem e n t for t h e prevention of t h e spread of disease a n d t h e adequate t r e a t m e n t of t h e infected t h a t would include a n d improve the provisions of t h e Brussels A g r e e m e n t for seafarers, a n d would provide for t h e needs of m i g r a n t s a n d displaced p e r s o n s ; (3) the recidivist of b o t h sexes a m o n g V.D. p a t i e n t s ; a n d (4) t h e place of the general practitioner in t h e fight against venereal disease. In spite of difficult conditions in Paris owing to the strike at t h e e n d of October, several representatives from e a c h of 15 nations a n d f r o m f o u r international organisations attended. D u r i n g the past year the U n i o n h a s established a Regional office with t h e aid of a financial contribution a n d loan of staff f r o m t h e A m e r i c a n Social H y g i e n e Association. Its activities have included a tour t h r o u g h the South A m e r i c a n Republics by M. Fleursheim, Hon. T r e a s u r e r of t h e Union. Dr. W i l l i a m Snow, Hon. Director of t h e A m e r i c a n Social H y g i e n e Association a n d a m e m b e r of the Consultative C o m m i t t e e of the Federal G o v e r n m e n t H e a l t h D e p a r t m e n t , presided over the meetings as t h e newly elected President of t h e Union. France anti Italy were represented b y t h e Secretaries of their H e a l t h Departments. Dr. Heller, Chief of the U.S.A. Federal V.D. D e p a r t m e n t , attended as one of t h e A m e r i c a n delegation a n d was elected a T e c h n i c a l Adviser. T h e R u s s i a n delegatiorr of p r o m i n e n t venereologists were u n f o r t u n a t e l y delayed a n d a r r i v e d after t h e final a n d plenary Session. T h e F r e n c h Reception C o m m i t t e e h a d planned to show the delegates t h e f u n c t i o n i n g of their V.D. s c h e m e in t h e devastated areas a n d in seaports b y a r r a n g i n g a two-day motor coach tour t h r o u g h Rouen, Havre, Honfieur a n d Caen. Generous hospitality was accorded by t h e civic a n d medical authorities at each stopping place. Dr. F o r g a n represented the Central Council for H e a l t h E d u c a t i o n as official British delegate, a n d Colonel L. W. Harrison, c.B., Technical Adviser f r o m t h e Ministry of H e a l t h , and Mrs. Neville-Rolfe, O.B.E., Vice-President of the Union, also attended. T h e discussion on penicillin showed a m u c h more conservati~'e attitude towards its use for V?.D. a m o n g the F r e n c h dermatologists t h a n in t h e U.S.A. a n d Great Britain. M a n y countries h a d n o t h a d a sufficient supply for it to be in general use at the V.D. clinics. Of great interest was Dr. Heller's account of the rapidly developed quick t r e a t m e n t centres in t h e U.S.A. t h r o u g h w h i c h some 180,000 patients pass per a n n u m . T h e prevalence of recidivism h a d been t h r o w n into relief, a n u m b e r of patients of b o t h sexes h a v i n g reappeared four times within t h e year with new infections. T h e question of relapse was raised, b u t Dr. Heller m a i n t a i n e d t h e two conditions were clearly distinguishable. T h e h a r m arising from the issue of penicillin in tablet f o r m a n d its irresponsible use by t h e public, was r e n d e r i n g it useless in m a n y cases as a cure for serious conditions. T h e F r e n c h were p a r t i o i larly insistent on this point a n d a resolution was passed d r a w i n g the attention of all medical a u t h o r i t i e s to t h e danger.
PUBLIC H E A L T H , J a n u a r y , 1948
68 A lively discussion was based on t h e papers f r o m fonr countries (of w h i c h Colonel H a r r i s o n c o n t r i b u t e d one) on t h e part the general p r a c t i t m n e r s can play in the fight a g a i n s t V.D. All were u n a n i m o u s t h a t their coroperation was essential, b u t h i t h e r t o their assistance in contact t r a c i n g h a d n o t been f o r t h c o m i n g a n d in m o s t countries their co-operation with t h e clinic medical staffs was not close. Dr. F o r g a n aroused considerable interest in describing the E d i n b u r g h s c h e m e where co-operation Over a wide area h a s worked successfully for some years. T h e time involved in contact tracing a n d preventive m e a s u r e s was recognised, a n d a resolution u r g i n g t h a t t i m e so spent s h o u l d be p a i a for by t h e h e a l t h a u t h o n t i e s was a d o p t e d for circulation to governments. T h e question of t h e Brussels A g r e e m e n t , its a m e n d m e n t a n d the revival of the Ports C o m m i s s i o n by the U n i o n was raised by Mrs. Nevitle-Rolfe. Dr. Guthe, Secretary of t h e V.D. Sub-committee of t h e I n t e r i m C o m m i s s i o n of W.H.O., outlined t h e present position of t h e Brussels A g r e e m e n t a n d indicated t h a t its revision would involve a two years' process t h r o u g h diplomatic c h a n n e l s while its r e p l a c e m e n t b y W.H.O. regulations would become effective forthwith. T h e U n i o n , at their Council m e e t i n g in May, h a d already raised the need for some similar m e a s u r e s to meet t h e needs of m i g r a n t s a n d to enable t h e infected to be traced across frontiers. T h e I n t e r i m C o m m i s s i o n h a d appointed t h e V.D. C o m m i t t e e to s t u d y t h e possible scope of a n I n t e r n a t i o n a l V.D. a r r a n g e m e n t covering b o t h aspects of t h e question, seafarers a n d m i g r a n t s . Delegates f r o m several countries cited t h e additional difficulties-that arose f r o m large bodies of alien labour a n d displaced persons living in c a m p s t h r o u g h o u t Europe. T h e s e persons faced social c o n d i u o n s as d a n g e r o u s to h e a l t h as those of t h e seafarer before t h e m o v e m e n t to improve port conditions a n d provide treatment. T h o u s a n d s of m e n were separated f r o m their h o m e s a n d families while recreative facilities a n d amenities were u s u a l l y quite inadequate: T h e U n i o n set up a C o m m i t t e e u n d e r t h e c h a i r m a n s h i p of Dr. H e r m a n s of Holland, c h a r g e d with t h e d u t y of s t u d y i n g b o t h aspects of t h e problem. T h e C o m m i t t e e would work in two parts where t h e interests of t h e seafarer a n d t h e m i g r a n t diverged so t h a t p l a n s for b o t h should be prepared. It was fully recognised t h a t all special provisions, s u c h as dockside clinics a n d port welfare, s h o u l d be preserved in a n y wider m e a s u r e for t h e intern a t i o n a l prevention a n d t r e a t m e n t of V.D. T h e U n i o n have asked W.H.O. to assist t h e m financially in c o n v e n i n g a n International V o l u n t a r y Conference in the c o m i n g , m o n t h s to w h i c h N a t i o n a l bodies a n d experts can be invited. T h e need for collecting opinions a n d experience f r o m as wide a field as possible, so t h a t alI available i n f o r m a t i o n a n d ideas can reach t h e W.H.O. while the m a t t e r is u n d e r discussion, was appreciated. It was i n f o r m a l l y suggested t h a t t h e delegates of each m a r i t i m e c o n n t r y s h o u l d e n d e a v o u r to p r o m o t e a N a t i o n a l V o l u n t a r y Conference of all concerned with t h e Brussels A g r e e m e n t and with m i g r a n t s a n d alien labour, from w h i c h a delegation could be appointed to t h e I n t e r n a t i o n a l Voluntary C o n f e r e n c e . W h i l e g o v e r n m e n t s can provide statistical returns a n d official reports, it was held t h a t m a n y points would be raised b y i n d i v i d u a l s of experience a n d non-official bodies at s n c h conferences, w h i c h could n o t find a place in t h e g o v e r n m e n t statements. Mrs. Neville-Rolfe's report on Sex B e h a v i o u r a n d Venereal Disease was t h e basis of a lively discussion. It was agreed u n a n i m o u s l y to adopt t h e suggestion t h a t a Study C o m m i t t e e should be appointed of w h i c h she was elected C h a i r m a n . M a n y offers were m a d e to participate in a n international e n q u i r y t h r o u g h t h e clinics a n d their social services into the b a c k g r o u n d of the recidivist. T h e second item referred for e n q u i r y was t h e type of biological t e a c h i n g related to h u m a n affairs a n d t h e content of sex g u i d a n c e related to the fatflily t h a t was b e i n g given in each country. In this e n q u i r y the co-operation a n d advice of U.N.E.S.C.O. is to be sought.
Askwith Agreement~Second Interim Revision.--For t h e information of m e m b e r s , t h e position is t h a t all t h e bodies concerned, except t h e L,C.C,, have now confirmed t h e r e c o m m e n d a t i o n s of t h e conference held at t h e M i n i s t r y of H e a l t h on J u l y 28th last. T h e formal confirmation of t h e L.C.C. is expected shortly, w h e r e u p o n the M i n i s t r y will circulate t h e d o c u m e n t to all local authorities. T h e new percentage increases will be applicable f r o m J u l y 1st last. New Year Honours.~We congratulate two m e m b e r s of t h e Society whose n a m e s a p p e a r e d in t h e list, viz., Lieut.-General T. O. T h o m p s o n (until recently Director of Medical Services, India) who becomes K n i g h t - C o m m a n d e r , Order of t h e Star of India, a n d Dr. Victoria M a r y Crosse (Dep. Sen. A.M.O.H., B i r m i n g h a m ) who receives the Order of t h e British Empire. A d v e r t i s e m e n t s of appointments, courses, etc., appear on p. vii, f a c i n g p. 72.
SOCIETY
OF
MEDICAL
OFFICERS
OF H E A L T H
COUNCIL MEETING A m e e t i n g of t h e Council was held in t h e H a s t i n g s Hall, Tavistock House, L o n d o n , W.C.I, on Friday, N o v e m b e r 28th, 1947, at 10 a.m. T h e r e were present t h e C h a i r m a n of Council (Dr. G. F. Buchan), the President (Dr. F. Hall) a n d Drs. Cyril Banks, Fraser Brockington, G. L. Brocklehurst, C. Metcalfe Brown, H. A. B u l m a n , H. D. Chalke, W. G. Clark, C. K. Cullen, Sir Allen Daley, Dr. R. H. G. Hector D e n h a m , Sir George Elliston, Dr. M i r i a m Florentin, Prof. W. M. Frazer, Drs. R. M. Galloway, J. M. Gibson, F. Gray, A. S. Hebblethwaite, C. Herington, K a t h e r i n e Hirst, Sir W i l s o n J a m e s o n , Prof. J. J o h n s t o n e Jervis, Drs. R. H. H. Jolly, R. A. Leader, ProL J. M. M a c k i n t o s h , Drs. J o h n Maddison, A. Morrison, A. A. E. Newth, H. L. Oldershaw, W y n d h a m Parker, Prof. R. H. Parry, Drs. H. Paul, D. D. Payne, Prof. R, M. F. Picken~ Dr. T. RuddockWest, J. E. Spence, Mr. A. Gordon Taylor, Drs. N o r a Wattle, H. C. M a u r i c e W i l l i a m s a n d F. T. I-t; Wood. Apologies for absence were received from Drs. Jas. Fenton, J. A. Stirling a n d J. A. Struthers. T h e C h a i r m a n welcomed Drs. H. L. Oldershaw a n d J. E. Spence on their r e t u r n to t h e Council after an interval a n d t h e following new m e m b e r s who were a t t e n d i n g their first m e e t i n g : Drs. G. L. Brocklehurst, H. D. Chalke, R. H. G. Hector D e n h a m , D. D. P a y n e a n d T. R u d d o e k - W e s t . Election o[ Departmental Officers under Article 19 ( d ) . - - T h e folIowiug were elected on t h e n o m i n a t i o n of t h e Inter-Group Committee: Drs. M i r i a m F l o r e n t i n a n d A. Morrison, a n d Mr, J. v . Bingay, Ln.s. Minutes of t h e m e e t i n g h e l d on September 19th, p u b l i s h e d in PUBLic HEaLTg, October, p. 14, were confirmed a n d signed b y t h e Chairman. Report of the General Purposes Committee.--Dr. J. M. Gibson (Chairman) presented t h e report a n d , r e c o m m e n d a t i o n s of t h e General Purposes C o m m i t t e e (see page 73). T h e s e were adopted with t h e following a d d i t i o n s a n d m o d i f i c a t i o n s : - Min. 73.--Salaries.--Dr. B u c h a n reported t h a t t h e B.M.A. representatives h a d visited the Minister of H e a l t h on O c t o b e r 28th a n d h a d i n f o r m e d t h e Minister t h a t there was objection to a proposal of a central council, c o n t a i n i n g n o n - m e d i c a l elements on the employees' side, w h i c h would have t h e last word in r e g a r d to t h e a m o u n t a n d conditions of m e d i c a l pay. Dr. W. G. Clark pointed o u t t h a t in Scotland t h e proposed W h i t l e y m a c h i n e r y excluded local a u t h o r i t y representatives on a c c o u n t of t h e latter's refusal to enter t h e scheme. He u r g e d t h a t t h e difference in t h e Scottish A c t m u s t be recognised. In t h e past Scottish public h e a l t h medical officers h a d suffered f r o m b e i n g o u t w i t h t h e A s k w i t h m a c h i n e r y . Min. 77.--Cremation Regulations.--As a result of discussion on t h e proposal b y Drs. B a n k s a n d W h i t e for t h e complete omission of t h e present F o r m C, it was decided to m o d i f y this r e c o m m e n d a t i o n so as to leave power for t h e referee to require a confirmatory certificate in cases where he considered this necessary, a n d t o give h i m the r i g h t of selecting t h e practitioner to complete F o r m C. R e g a r d i n g oral evidence it was agreed t h a t Dr. B a n k s s h o u l d be n o m i n a t e d .
Min. 78.--Superintendent Nursing Officers and Health Visitors.--The Council considered c o m m e n t s f r o m t h e M. & C.W. .Group on t h e Royal College of N u r s i n g m e m o r a n d u m regardm g t h e duties a n d conditions of service of s u p e r i n t e n d e n t h e a l t h visitors a n d correspondence between t h e W o m e n Public H e a l t h Officers Association a n d t h e M i n i s t r y of H e a l t h regardi n g the a p p o i n t m e n t s of s u p e r i n t e n d i n g n u r s i n g officers suggested in t h e M i n i s t r y ' s Circular 118/47, para. 27. The Council opinion : - -
adopted .. t h e
following
expressions
of
(a) T h e r e are very few people who would be qualified at one a n d t h e s a m e time to s u p e r i n t e n d I t e a l t h Visitors, Domiciliary Midwives a n d District Nurses. (b) S u p e r i n t e n d e n t H e a l t h Visitors a n d Supervisors of Midwives at t h e present time work a m i c a b l y on an equal footing, w i t h o u t t h e i n t e r v e n t i o n of a Superintendent N u r s i n g Officer. (c) T h e three different services are such t h a t t h e y c a n n o t be " r o l l e d " into one, a n d t h e Medical Officer of H e a l t h is t h e only person to co-ordinate these duties.
Min. 80.--Sanitary Provision by Railway Companies.--Agreei n g the action proposed b y t h e Committee, the Council decided to ask t h e M i n i s r y of H e a l t h to encourage t h e o b t a i n i n g of