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MALARIA AND THE POPULATION EXPLOSION
346 would be allowed, and an order made for the defendant’s detention in Broadmoor pending his trial. R. v. Robertson. Court of Appeal, Criminal Division; Lord Parker, C.]., Melford Stevenson and Bridge, -7_7. July 30, 1968. Counsel and solicitors: Roger Frisby (Kingsley Napley & Co.); Robert Harman (Director of Public Prosecutions).
L. NORMAN WILLIAMS Barrister-at-Law.
Appeal against Damages Dismissed On July 30, 1968, the Appeal Committee of the House of Lords (Lord GUEST, Lord PEARCE, and Lord WILBERFORCE) refused a petition for leave to appeal from the decision of the Court of Appeal in Hucks v. Cole1 which dismissed an appeal by a doctor whose patient had been awarded damages for the effects of fulminating septicxmia. An obstetrician later discussed the case in our correspondence columns.2
N.H.S. Tribunals In 1967, the Council on Tribunals3 heard of a number of which suggested that more should be done to advise dental patients of their rights under the N.H.S. In particular, the terms of service might be altered so that a dentist who proposed to take on a former N.H. S. patient must give him a written statement saying that he was now outside the N.H.S. The Ministry of Health agreed that the situation should be clarified in writing but saw practical difficulties in amending the terms of service. The joint discussions4 on a charter for the family-doctor service contained a proposal that the handling of complaints about general medical services should include provision for an informal procedure whereby a lay member of the executive council, assisted by a doctor, could act as conciliator in certain cases. The Council thought this a useful proposal, but felt that it should be made clear that the right of formal inquiry would not be prejudiced by an informal investigation, and that the formal and informal procedures should be kept entirely separate. The Council had discussed the proposal with the Ministry. The Council thought that the conciliator should consult the chairman of the service committee before dealing with a complaint informally, and that this chairman should be sent correspondence dealing with cases where the complainant did not wish for a formal inquiry. The profession disagreed with both suggestions, but did agree to the papers being sent to the chairman of the executive council. In Scotland, where doctors are satisfied with existing procedures, no informal procedure will be introduced. cases
1. Lancet, 1968, i, 1097. 2. Hudson, C. N. ibid. p. 1194. 3. Annual Report of the Council on Tribunals for 1967. H.M. Office, 1968. Pp. 41. 4s. 6d. 4. Br. med. J. 1966, i, suppl. p. 135.
Stationery
In England Now ENGLAND’S (AND WALES’) GREEN AND PLEASANT And do all minds in modern time Read about England’s paper, green ? And is the guiding hand of Ken On Bevan’s present tripod seen ? And does the covenant sublime Shine forth upon our welfare ills ? And are health areas builded there Among some bureaucratic bills ?
Bring Bring Bring Bring
me me me
me
my pen of burnished my typists of desire!
gold!
my ’phone! 0 files, unfold! my in and out trays (wire)!
I will not cease from mental health, Nor shall my scheme stop at the Lords Till I have planned Utopia In England’s green-bound paper Boards.
PAPER
Letters
to
the Editor
MALARIA AND THE POPULATION EXPLOSION SIR,-Your leading articlecites findings of Newman,2 Meegama,3 and myself 4-6with particular reference to Ceylon, and concludes " that public-health action of one sort or another has been almost entirely responsible for the population explosion since 1945 ". I wish to restate some of the available evidence which seems to lead to a somewhat different conclusion. Endemic malaria had been one of the most important health problems in the tropics. Effective control after the 1939-45 war seemed to be associated with dramatic reductions in the death-rates and with sharp increases in the rates of population growth. Ceylon is the most notable case in point. Noting the approximate coincidence of the post-war extension of insecticides and the dramatic reduction in the death-rate from all causes per 1000 population from 20-3 in 1946 to 14-3 in 1947, the post-war decline in mortality in Ceylon has often been ascribed to the effective control of malaria. The dramatic reduction in mortality took place in the second half of 1946, when only 18% of the population had been protected by the residual spraying of the walls of their dwellings with insecticides. The mortality-rate from all causes declined from 21-3 in the second half of 1945 to 15-4 in the second half of 1946. Comparison of the mortality experience in the malarious area protected by insecticides and in the nonmalarious area unprotected by insecticides indicates that the number of deaths from all causes declined 26% in the protected malarious area, 24% in the unprotected non-malarious area, or 25% overall, from the second half of 1945 to the second half of 1946. Between the second halves of 1944 and 1947 all-cause mortality declined 30% in the protected malarious area, and 29% in the unprotected non-malarious area, or 29% overall. If the entire difference between the reductions in mortality in the districts without malaria and without malaria control and the reductions in the island-wide mortality is attributed exclusively to malaria control, obviously this would establish malaria control as neither the sole nor even the major factor in the post-war reduction in the island-wide mortality.4 Because of the inverse association of the prevalence of people with the prevalence of malaria, greater relative reductions in the death-rates, whatever the cause, in a few of the most malarious but also most sparsely populated districts, contributed only little to the reduction in the island-wide deathrate. Thus, malaria and its effective control had little effect Malaria on the island-wide mortality trends in Ceylon. having been a major cause of disease but not of death, control of malaria has increased the quality rather than the quantity of life. Moreover, malaria control has removed what had been an insurmountable barrier to the development of the greater part of the island. By opening up the major area of Ceylon to development, the net effect of the control of malaria had been paradoxical-namely, a reduction in population pressure. The death-rate of Ceylon had displayed a long-term downtrend, with a war-time interruption of the long-term downtrend and a post-war drop from the wartime peak to the longterm down-trend. Thus the wartime rise in mortality, rather than the post-war decline, has been the notable event.5 Having ruled out malaria control as the primary cause of the post-war decline in mortality, the level of nutrition was examined for fluctuations which might have influenced the death-rates to rise during the war and to return to the longterm down-trend following the war. It was found that the 1. 2.
Lancet, 1968, i, 899. Newman, P. Malaria Eradication and Population Growth with Special
3. 4. 5. 6.
Ceylon and British Guiana. Bureau of Public Health no. 10, University of Michigan School of Public Health, Ann Arbor, 1945. Meegama, S. A. Population Studies, 1967, 21, 207. Frederiksen, H. Pub. Hlth Rep., Wash. 1960, 75, 865. Frederiksen, H. ibid. 1961, 76, 659. Frederiksen, H. ibid. 1966, 81, 715. Reference
to
Economics, research series
347
wartime rise and post-war fall in the death-rate was associated with the development and alleviation of a wartime food deficit. The timing and extent of the food deficit are indicated by the wartime decline in food imports, which represented the principal source of staple foods for Ceylon. Following the war, food imports again increased sharply and by 1947 exceeded the pre-war level. The mortality trends were especially correlated with the levels of nutrition rather than availability of health services. The relationship between mortality trends and levels of living is also indicated by comparisons of the direction and timing of concurrent changes in a range of economic and social indices. Thus, in 1947, when the death-rate had returned from a wartime peak to the previous long-term downtrend, personal consumption at constant prices had risen sharply above the level of 1938, whereas per-capita health expenditures had remained at the 1938 level. It is evident that levels of living and mortality trends in Ceylon have displayed a remarkable inverse association. Beginning with 1938, mortality was cut in half when personal consumption had doubled in the course of about 15 years.5 It may seem as if my intention has been to exonerate malaria control from undue blame for a population explosion in Ceylon. Rather, malariologists should not claim undue credit for the reduction in mortality. In fact, a reduction in mortality is a good thing. Aside from humanitarian considerations, increasing longevity provides increasing returns from investments in human resources. Moreover, a reduction in mortality may contribute toward a balancing reduction in fertility.s Aside from environmental factors that influence the size of family needed, wanted, or accepted, one might consider those factors that influence the active or passive achievement of a given family size. In the face of declining mortality or increasing survival of children, parents will need and may want to limit fertility to achieve the customary or a more practical family size. The incipient reduction of island-wide fertility, following the reduction in mortality, suggests that Ceylon is repeating the historic process of economic and demographic transition from low to high levels of consumption and production, and from high to low levels of mortality and fertility. As levels of living rise, mortality declines. In a balancing movement, fertility tends toward approximate equilibrium with mortality. The feedback mechanism of this system of hommostasis has been obscured by attempts to relate reductions in fertility exclusively to improvements in economic and social components in the levels of living; in fact a deliberate reduction in fertility may be a sequel to a reduction in mortality, which develops individual and collective motivation, as well as need, for a commensurate restraint of fertility. Population and Program Analysis Division, Population Service, Agency for International Development,
Washington,
D.C.
HARALD FREDERIKSEN.
HEALTH AND SOCIAL SERVICES SIR,-It is with concern that I have read the paragraph in the Seebohm report on the social services7 dealing with the proposed future of the local-authority child-guidance services. These at present provide a full psychiatric service, including treatment, for the greater part of the child population of this country; the National Health Service provides few childguidance clinics, except in the big cities. The Seebohm report proposes that the new social-services department of the local authority should take over the staffs of the childguidance centres, that the role of the psychiatrist should be largely advisory, and that children needing treatment should be referred elsewhere, presumably to clinics run by the N.H.S., which do not exist in most areas. Unless the Government is willing and able to provide and staff such clinics, the adoption 7. Report of the Committee on Local Authority and Allied Personal Social Services. H.M. Stationery Office, 1968. See Lancet, July 27,
1968, p. 201.
of this report will
that children in need of psychiatric be able to get it. Enfield Child Guidance Clinic, ALAN S. CLARK. Enfield, Middlesex.
treatment will no The
mean
longer
RESUSCITATION OF THE NEWBORN SiR,ńThe debate on the recommendation of the Central Midwives Board, that all midwives should be taught to intubate the apnoeic newborn infant as part of their routine training, ought surely to be settled in terms of the effects on the clinical status of the potential patients rather than on the professional status of the potential midwives.2 The essential point was made by Dr. Rosen and Professor Mushing and I should like to strongly support them. Inflation by bag and mask with an oropharyngeal airway in position is a procedure which can be easily learnt and safely and efficiently carried out by the occasional operator (as we have proved in the special-care nursery of this hospital over the past 5 years): intubation is not (as anyone knows who has the responsibility of training a succession of new resident medical staff). Only when faced with the need to apply the procedure almost daily (and nightly) in a wide variety of babies in real life-or-death situations can anyone, whatever his background, acquire the necessary skill and judgment, which can then be maintained by regular but relatively infrequent repetition. A very few midwives working in certain very active hospital units may need to be trained to intubate, at the discretion of those who are clinically responsible for the welfare of the patients: the remainder, who form the vast majority, are much more likely to do an efficient job without the same risk of causing harm, if they are taught to use a bag and mask to deal with the very occasional unforeseen emergency. How occasional this should be for the domiciliary midwife is illustrated by the finding of the Newcastle Maternity Survey,3 carried out at a period (1960-62) before the city’s midwives had been equipped with bag and mask. It was found that in only one out of every thousand deliveries in the home could a more effective method of resuscitation conceivably have been of benefit: this would be once in a professional lifetime in domiciliary midwifery. Our midwives are now equipped with such a method-bag and mask, and oro-
pharyngeal airway. Paediatric Research Unit, Princess Mary Maternity Hospital, Great North Road, Newcastle upon Tyne 2.
G. A. NELIGAN.
SIR,-Endotracheal intubation is invaluable for babies who need it, but dangerous, whether they need it or not, when
clumsily performed or attempted, as Dr. Towers points out (July 27, p. 218). Professor Scott (July 20, p. 167), and Dr. Barrie and the Central Midwives Board4 apparently consider that midwives should add this skill to their repertoire. Certainly a midwife can become just as dexterous as a doctor, but how can this proficiency be achieved and maintained ? Setting aside the actual selection of cases deemed to require intubation, the technique can be fairly easily demonstrated on models and cadavers, but to carry it out in the living patient with dexterity, speed, and gentleness, is an art not easily come by. Only by sustained endeavour can the essential skill be reached, and by constant practice maintained. Dr. Rosen and Professor Mushin1 have made this quite clear. To remain proficient the operator must be doing endotracheal intubation every day, preferably several times a day. Here in this small unit which deals only with abnormal midwifery, of the roughly 500 babies delivered annually by midwives (coesarean sections and other deliveries by doctors, such as
forceps
and breech
extractions, excluded)
about
1%might
Rosen, M., Mushin, W. W. Lancet, 1968, i, 1307. Scott, J. S. ibid. July 20, 1968, p. 167. Russell, J. K., Fairweather, D. V. I., Millar, D. G., Brown, A. M., Pearson, R. C. M., Neligan, G. A., Andersen, G. S. ibid. 1963, i, 711. 4. Barrie, H. ibid. 1968, i, 1103.
1. 2. 3.
L. NORMAN WILLIAMS Barrister-at-Law.
Appeal against Damages Dismissed On July 30, 1968, the Appeal Committee of the House of Lords (Lord GUEST, Lord PEARCE, and Lord WILBERFORCE) refused a petition for leave to appeal from the decision of the Court of Appeal in Hucks v. Cole1 which dismissed an appeal by a doctor whose patient had been awarded damages for the effects of fulminating septicxmia. An obstetrician later discussed the case in our correspondence columns.2
N.H.S. Tribunals In 1967, the Council on Tribunals3 heard of a number of which suggested that more should be done to advise dental patients of their rights under the N.H.S. In particular, the terms of service might be altered so that a dentist who proposed to take on a former N.H. S. patient must give him a written statement saying that he was now outside the N.H.S. The Ministry of Health agreed that the situation should be clarified in writing but saw practical difficulties in amending the terms of service. The joint discussions4 on a charter for the family-doctor service contained a proposal that the handling of complaints about general medical services should include provision for an informal procedure whereby a lay member of the executive council, assisted by a doctor, could act as conciliator in certain cases. The Council thought this a useful proposal, but felt that it should be made clear that the right of formal inquiry would not be prejudiced by an informal investigation, and that the formal and informal procedures should be kept entirely separate. The Council had discussed the proposal with the Ministry. The Council thought that the conciliator should consult the chairman of the service committee before dealing with a complaint informally, and that this chairman should be sent correspondence dealing with cases where the complainant did not wish for a formal inquiry. The profession disagreed with both suggestions, but did agree to the papers being sent to the chairman of the executive council. In Scotland, where doctors are satisfied with existing procedures, no informal procedure will be introduced. cases
1. Lancet, 1968, i, 1097. 2. Hudson, C. N. ibid. p. 1194. 3. Annual Report of the Council on Tribunals for 1967. H.M. Office, 1968. Pp. 41. 4s. 6d. 4. Br. med. J. 1966, i, suppl. p. 135.
Stationery
In England Now ENGLAND’S (AND WALES’) GREEN AND PLEASANT And do all minds in modern time Read about England’s paper, green ? And is the guiding hand of Ken On Bevan’s present tripod seen ? And does the covenant sublime Shine forth upon our welfare ills ? And are health areas builded there Among some bureaucratic bills ?
Bring Bring Bring Bring
me me me
me
my pen of burnished my typists of desire!
gold!
my ’phone! 0 files, unfold! my in and out trays (wire)!
I will not cease from mental health, Nor shall my scheme stop at the Lords Till I have planned Utopia In England’s green-bound paper Boards.
PAPER
Letters
to
the Editor
MALARIA AND THE POPULATION EXPLOSION SIR,-Your leading articlecites findings of Newman,2 Meegama,3 and myself 4-6with particular reference to Ceylon, and concludes " that public-health action of one sort or another has been almost entirely responsible for the population explosion since 1945 ". I wish to restate some of the available evidence which seems to lead to a somewhat different conclusion. Endemic malaria had been one of the most important health problems in the tropics. Effective control after the 1939-45 war seemed to be associated with dramatic reductions in the death-rates and with sharp increases in the rates of population growth. Ceylon is the most notable case in point. Noting the approximate coincidence of the post-war extension of insecticides and the dramatic reduction in the death-rate from all causes per 1000 population from 20-3 in 1946 to 14-3 in 1947, the post-war decline in mortality in Ceylon has often been ascribed to the effective control of malaria. The dramatic reduction in mortality took place in the second half of 1946, when only 18% of the population had been protected by the residual spraying of the walls of their dwellings with insecticides. The mortality-rate from all causes declined from 21-3 in the second half of 1945 to 15-4 in the second half of 1946. Comparison of the mortality experience in the malarious area protected by insecticides and in the nonmalarious area unprotected by insecticides indicates that the number of deaths from all causes declined 26% in the protected malarious area, 24% in the unprotected non-malarious area, or 25% overall, from the second half of 1945 to the second half of 1946. Between the second halves of 1944 and 1947 all-cause mortality declined 30% in the protected malarious area, and 29% in the unprotected non-malarious area, or 29% overall. If the entire difference between the reductions in mortality in the districts without malaria and without malaria control and the reductions in the island-wide mortality is attributed exclusively to malaria control, obviously this would establish malaria control as neither the sole nor even the major factor in the post-war reduction in the island-wide mortality.4 Because of the inverse association of the prevalence of people with the prevalence of malaria, greater relative reductions in the death-rates, whatever the cause, in a few of the most malarious but also most sparsely populated districts, contributed only little to the reduction in the island-wide deathrate. Thus, malaria and its effective control had little effect Malaria on the island-wide mortality trends in Ceylon. having been a major cause of disease but not of death, control of malaria has increased the quality rather than the quantity of life. Moreover, malaria control has removed what had been an insurmountable barrier to the development of the greater part of the island. By opening up the major area of Ceylon to development, the net effect of the control of malaria had been paradoxical-namely, a reduction in population pressure. The death-rate of Ceylon had displayed a long-term downtrend, with a war-time interruption of the long-term downtrend and a post-war drop from the wartime peak to the longterm down-trend. Thus the wartime rise in mortality, rather than the post-war decline, has been the notable event.5 Having ruled out malaria control as the primary cause of the post-war decline in mortality, the level of nutrition was examined for fluctuations which might have influenced the death-rates to rise during the war and to return to the longterm down-trend following the war. It was found that the 1. 2.
Lancet, 1968, i, 899. Newman, P. Malaria Eradication and Population Growth with Special
3. 4. 5. 6.
Ceylon and British Guiana. Bureau of Public Health no. 10, University of Michigan School of Public Health, Ann Arbor, 1945. Meegama, S. A. Population Studies, 1967, 21, 207. Frederiksen, H. Pub. Hlth Rep., Wash. 1960, 75, 865. Frederiksen, H. ibid. 1961, 76, 659. Frederiksen, H. ibid. 1966, 81, 715. Reference
to
Economics, research series
347
wartime rise and post-war fall in the death-rate was associated with the development and alleviation of a wartime food deficit. The timing and extent of the food deficit are indicated by the wartime decline in food imports, which represented the principal source of staple foods for Ceylon. Following the war, food imports again increased sharply and by 1947 exceeded the pre-war level. The mortality trends were especially correlated with the levels of nutrition rather than availability of health services. The relationship between mortality trends and levels of living is also indicated by comparisons of the direction and timing of concurrent changes in a range of economic and social indices. Thus, in 1947, when the death-rate had returned from a wartime peak to the previous long-term downtrend, personal consumption at constant prices had risen sharply above the level of 1938, whereas per-capita health expenditures had remained at the 1938 level. It is evident that levels of living and mortality trends in Ceylon have displayed a remarkable inverse association. Beginning with 1938, mortality was cut in half when personal consumption had doubled in the course of about 15 years.5 It may seem as if my intention has been to exonerate malaria control from undue blame for a population explosion in Ceylon. Rather, malariologists should not claim undue credit for the reduction in mortality. In fact, a reduction in mortality is a good thing. Aside from humanitarian considerations, increasing longevity provides increasing returns from investments in human resources. Moreover, a reduction in mortality may contribute toward a balancing reduction in fertility.s Aside from environmental factors that influence the size of family needed, wanted, or accepted, one might consider those factors that influence the active or passive achievement of a given family size. In the face of declining mortality or increasing survival of children, parents will need and may want to limit fertility to achieve the customary or a more practical family size. The incipient reduction of island-wide fertility, following the reduction in mortality, suggests that Ceylon is repeating the historic process of economic and demographic transition from low to high levels of consumption and production, and from high to low levels of mortality and fertility. As levels of living rise, mortality declines. In a balancing movement, fertility tends toward approximate equilibrium with mortality. The feedback mechanism of this system of hommostasis has been obscured by attempts to relate reductions in fertility exclusively to improvements in economic and social components in the levels of living; in fact a deliberate reduction in fertility may be a sequel to a reduction in mortality, which develops individual and collective motivation, as well as need, for a commensurate restraint of fertility. Population and Program Analysis Division, Population Service, Agency for International Development,
Washington,
D.C.
HARALD FREDERIKSEN.
HEALTH AND SOCIAL SERVICES SIR,-It is with concern that I have read the paragraph in the Seebohm report on the social services7 dealing with the proposed future of the local-authority child-guidance services. These at present provide a full psychiatric service, including treatment, for the greater part of the child population of this country; the National Health Service provides few childguidance clinics, except in the big cities. The Seebohm report proposes that the new social-services department of the local authority should take over the staffs of the childguidance centres, that the role of the psychiatrist should be largely advisory, and that children needing treatment should be referred elsewhere, presumably to clinics run by the N.H.S., which do not exist in most areas. Unless the Government is willing and able to provide and staff such clinics, the adoption 7. Report of the Committee on Local Authority and Allied Personal Social Services. H.M. Stationery Office, 1968. See Lancet, July 27,
1968, p. 201.
of this report will
that children in need of psychiatric be able to get it. Enfield Child Guidance Clinic, ALAN S. CLARK. Enfield, Middlesex.
treatment will no The
mean
longer
RESUSCITATION OF THE NEWBORN SiR,ńThe debate on the recommendation of the Central Midwives Board, that all midwives should be taught to intubate the apnoeic newborn infant as part of their routine training, ought surely to be settled in terms of the effects on the clinical status of the potential patients rather than on the professional status of the potential midwives.2 The essential point was made by Dr. Rosen and Professor Mushing and I should like to strongly support them. Inflation by bag and mask with an oropharyngeal airway in position is a procedure which can be easily learnt and safely and efficiently carried out by the occasional operator (as we have proved in the special-care nursery of this hospital over the past 5 years): intubation is not (as anyone knows who has the responsibility of training a succession of new resident medical staff). Only when faced with the need to apply the procedure almost daily (and nightly) in a wide variety of babies in real life-or-death situations can anyone, whatever his background, acquire the necessary skill and judgment, which can then be maintained by regular but relatively infrequent repetition. A very few midwives working in certain very active hospital units may need to be trained to intubate, at the discretion of those who are clinically responsible for the welfare of the patients: the remainder, who form the vast majority, are much more likely to do an efficient job without the same risk of causing harm, if they are taught to use a bag and mask to deal with the very occasional unforeseen emergency. How occasional this should be for the domiciliary midwife is illustrated by the finding of the Newcastle Maternity Survey,3 carried out at a period (1960-62) before the city’s midwives had been equipped with bag and mask. It was found that in only one out of every thousand deliveries in the home could a more effective method of resuscitation conceivably have been of benefit: this would be once in a professional lifetime in domiciliary midwifery. Our midwives are now equipped with such a method-bag and mask, and oro-
pharyngeal airway. Paediatric Research Unit, Princess Mary Maternity Hospital, Great North Road, Newcastle upon Tyne 2.
G. A. NELIGAN.
SIR,-Endotracheal intubation is invaluable for babies who need it, but dangerous, whether they need it or not, when
clumsily performed or attempted, as Dr. Towers points out (July 27, p. 218). Professor Scott (July 20, p. 167), and Dr. Barrie and the Central Midwives Board4 apparently consider that midwives should add this skill to their repertoire. Certainly a midwife can become just as dexterous as a doctor, but how can this proficiency be achieved and maintained ? Setting aside the actual selection of cases deemed to require intubation, the technique can be fairly easily demonstrated on models and cadavers, but to carry it out in the living patient with dexterity, speed, and gentleness, is an art not easily come by. Only by sustained endeavour can the essential skill be reached, and by constant practice maintained. Dr. Rosen and Professor Mushin1 have made this quite clear. To remain proficient the operator must be doing endotracheal intubation every day, preferably several times a day. Here in this small unit which deals only with abnormal midwifery, of the roughly 500 babies delivered annually by midwives (coesarean sections and other deliveries by doctors, such as
forceps
and breech
extractions, excluded)
about
1%might
Rosen, M., Mushin, W. W. Lancet, 1968, i, 1307. Scott, J. S. ibid. July 20, 1968, p. 167. Russell, J. K., Fairweather, D. V. I., Millar, D. G., Brown, A. M., Pearson, R. C. M., Neligan, G. A., Andersen, G. S. ibid. 1963, i, 711. 4. Barrie, H. ibid. 1968, i, 1103.
1. 2. 3.