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National insurance, public health and school hygiene
PUBLIC H E A L T H . NATIONAL INSURANCE, PUBLIC H E A L T H AND S C H O O L H Y G I E N E . BY H. M E R E D I T H RICHARDS, M.D., Croydon.
NO T E . - - C l a u s e s 43 to 47, dealing with Local ttealth Committees, Excessive Sickness and the Provision of Sanatoria will be discussed in Parliament while this paper is in the printer's hands. For the moment it is assumed that (subject to the Government amendments) these clauses will be passed in their present form. introducing this discussion I shall conI N fine myself as closely as possible to the broader Public Health aspects of the Insurance Bill, which I am assuming will pass into law without any substantial change, other than what is contained in the various amendments that have been proposed or accepted by the Government. It is to be hoped that we shall refrain for the moment from discussing alternative schemes. To do so at this juncture would serve no useful purpose and tend to divert oui discussion from pressing practical problems. Similarly I propose, on this occasion, to put on one side such interesting topics as the prevention of malingering; the contributions to be paid and the benefits to be received by various classes of insured persons, together with the whole problem of domiciliary medical attendance. The last subject has already been adequately discussed by other medical societies, and personally I have little to add to the suggested scheme which has been published in the " Lancet " and elsewhere. The National Insurance Bill is intended " to provide for insurance against loss of health and for the prevention and cure of sickness." Its purpose is therefore two-fold, viz. : (I) to provide material aid in time of sickness, and (2) to prevent and cure disease. Obviously the latter object is, in the main, the more important, and hence the necessity for enquiring how it can be most completely achieved. Clearly an insurance scheme in which the underwriters calculated their premiums according to past experience, and did not interest themselves in diminishing future risks would have no preventive value. As a matter of fact this attitude of detachment is not a necessary part of ordinary commercial insurance. In
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some instances (for example, policies covering the risk of a wet Coronation week) underwriters neither do nor can take any steps to diminish the risks against which they insure. In marine and fire insurance the conditions are for the most part quite different. The shipowner who wishes to insure a steamer at ordinary rates has to produce evidence that the vessel is pr6perly constructed, and to submit his vessel to a stringent periodical inspection by Lloyds' surveyors. Similarly fire insurance offices will not insure premises that are built of inflammable materials except at high premiums, and insist that special precautions shall be taken in respect to dangerous trades. In this way insurance does indirectly stimulate prevention by offering substantial financial advantages to those who adopt all available precautions. This will apply to sickness insurance. Societies which desire to build up reserves and to reduce their average duration of sick pay will have every inducement to press for greater efficiency it~ respect to the Medical and Sanatorium benefits, and to regard the activities of sanitary authorities with enlightened self-interest. They will, in fact, stand to gain as much from a preventive medical service as Fire Insurance Corporations gain from the public provision of fire extinguishing appliances, and, by their representation on the Insurance Committees, be in a very favourable position for giving effect to their wishes. In practice it is probable that the immediate effect of the Insurance Scheme on preventive medicine will be proportional to the initial bias of the new Insurance Committees, and to the extent to which their work is harmoniously co-ordinated with existing Public Health organisations. The constitution and duties of the new committees therefore require careful consideration. Tile committees will be appointed for every County and County Borough, and will consist of a nucleus of twenty-four to forty-eight members, to which the County and Borough Councils with the Insurance Commissioners will add two-thirds. The members will be appointed as follows :--Nominated by County or Borough Council ............ 8* or I6" Nominated by Insured persons ... 24 or 4 8 (proportion representing approved Societies to be settled by the Commissioners)
Medical practitioners appointed by those in practice in the district ........................... "~ T w o o f w h o m n l u s t 'be w o m e n ,
2
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1911. Medical practitioners appointed by the Insurance Commissioners ........................ Other persons ap'pointed by the Insurance Commissioners ...
1 5" or
i 13"
Total 4 ° or 8o There is also a proviso that the proportion nominated by County and Borough Councils may be increased if the County or Borough undertake any financial liability. In county areas it is intended to set up local Insurance Committees in the larger urban districts. It is to be hoped that those who are responsible for these appointments will realize how imperative it is that the best available representatives should be selected. In most districts it would be an advantage if the chairman and, or, vice-chairman of the Public Health and Hospitals Committees of the C o u n t y or Borough Council, and the chairman or vicechairman of the Medical Inspection Committee of the Education Committee were a m o n g those nominated to represent the County and Borough Councils. The duties of the new Insurance Committees include : - (I) Administration of Medical Benefit. With this I do not propose to deal for reasons already given.
(2) Administration of Sanatorium Benefit. This will be one of the most important functions of the committee, and can be more conveniently discussed at a later stage. (3) A,dministration of Sickness, Disable-
ment and Maternity Benefit in respect of Deposit Contributors. The amount of work involved in administering the benefits of the Post Office group will vary in different districts. To a large extent the actual administration will be settled by the scheme, but a very important function of the committee will consist in accumulating facts and in making suggestions in respect to what is, at present, a provisional and transitory part of the national scheme. (4) The amendment agreed with the re-
presentatives of County Councils and Corporations provides that the new committee " shall make such reports as t o the health of insured persons within the County or County Borough as the Insurance Commissioners, after consultation w i t h the Local Government Board, m a y prescribe, and shall furnish to them such statistical affd other returns as they may require, and may make such other reports * Two
Of w h 0 r n
must
b e WOtllel~.
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on the health of such persons, and the conditions affecting the same, and may make such suggestions with regard thereto as it may think fit, and the Insurance Commissioners shall forward to tlfe Councils of the Counties, County Boroughs, and County Districts, which appear to them to be affected by or interested in a n y such reports, returns, or suggestions, copies of such reports, returns, and suggestions." This is a most important duty of the committee which will require much expert knowledge and administrative skill if the central and local authorities are to have the information in a form which they can assimilate and use for practical ends. It is difficult to see how this can be effected unless the Committee has at its disposal a medical expert. It is true that it is proposed that the County, Borough or District medical officer of health may attend the committee, but he could hardly undertake the onerous duty of collating and analysing these statistics unless it were made incumbent on him by statute or by order of the Local Government Board. I suggest that the sickness returns should be furnished to the medical officer of health at weekly or monthly intervals, and that the Local Government Board should make it obligatory for the medical officer of health to report thereon to the Insurance Commissioners, Local Government Board, and to the locaI authority concerned, if the co-operation of the Registrar General is obtained, it would be possible to secure a uniform system of classification and to insure that sickness and death returns are, as far as possible, comparable. Such an arrangement would have m a n y advantages. County and Borough Councils could not object to their medical officer of health carrying out a statutory duty or to an)" necessary augmentation of his clerical staff. Recommendations arising out of the sickness returns would be more promptly dealt with, and with less danger of friction, if they arose on the independent report of the medical officer of health than if they were received in an undigested form from the Insurance Committee. The medical officer of health would be furnished with a solid basis of fact whereon to base recommendations for sanitary progress. As I have already shown elsewhere it is probable that one of the most important iesults that the Insurance scheme will bring about is the classification of the insured. Most of the difficulties of our public health and
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social problems are due to their complexity, and these difficulties will be considerably lightened if we can classify the population according to the healthiness or otherwise of their occupations, the part l~layed b y economic pressure in producing physical inefficiency and the results of intemperance and idleness. Thus the deposit contributors will eventually include (a) the physically defective ; (b) those who have been expelled from the Friendly Societies I~hrough misconduct; (c) those who have run out of benefit through idleness or through lack of employment. All this classification will be invaluable not merely for the purposes of the Insurance Bill but for laying the foundation whereon a reformed poor law must be built. On the other hand the classification will be unreliable and valueless unless the figures have been analysed b y someone who has not merely some mathematical training but is versed in the natural history of disease. (5) Excessive Sickness. The next duty of the new committee will be to make claims in respect to excessive sickness due to employment, housing, sanitary conditions, contaminated water supply or neglect of the Public Health and Factories Acts. Now the causes of sickness are so complex that it does not seem likely that claims will often be made good except in the comparatively simple cases of unhealthy occupations and of water epidemics. Obviously there is nothing inequitable in making an unhealthy trade bear its own burden, or in making a water authority responsible for supplying contaminated water. In other instances the knowledge that neglect of sanitary provisions may lead to financial liabilities is likely to stimulate the hygienic conscience even if claims for excessive sickness are seldom brought home. In any case immediate enquiry into the causes of actual or apparent excessive sickness should be a primary duty of the medical officer of health. I now come to the administration of Sanatorium benefit, i.e., Treatment in sanatoria or other institutions or otherwise when suffering from tuberculosis or such other diseases as the Local Government Board w~th the approval of the Treasury may appoint. In the Chancellor's most recent explanatory Memorandum (Cd. 5930, P. 2), it is stated that sanatorium treatment will be extended to wives, children, and dependants of insured persons, and " that the Treasury would make itself responsible to the extent of one-half for
DEam3Ea,
any expenditure u p o n such treatment which might not be covered b y the money available under the Bill, provided the persons or local authorities giving tile treatment make themselves responsible for the other half. Sanatorium treatment will be administered by the existing local health authorities or such other persons as may be approved b y the Local Government Board, and provided that they pay one-half of any cost in excess of tl!e amount provided b y the National hasurance Fund, the Treasury will undertake to pay the other half." It is not clear whether it is intended to make use of Poor Law institutions for the institutional treatment of the insured and of their dependants. From the Times report of the debate on Clause 47 it would appear that this point is reserved. I suggest that this Society might usefully point out the inadvisability of relegating any part of the contemplated treatment of phthisis to Poor Law authorities. Otherwise in certain districts we shall have overlapping, while in other districts we shall see Guardians and Borough Councils engaged in the familiar pastime of disclaiming responsibility for meeting the public needs. The treatment of phthisis should be made a Public Health obligation. Public Health authorities should also be given the power to initiate the extension of sanatorium benefit to the dependants of the insured and to deposit contributors who have run out of benefit. At present this extension is dependent on the action of the Insurance Committees, who m a y or may not be progressive bodies. The immense impetus that this will give not only to the provision of sanatoria but to other specialised methods both for detecting and for treating phthisis is obvious. As soon as the Insurance Bill becomes law local authorities will need advice as to the best way in which they can meet the needs of th~ insured and take advantage of the opportunity afforded b y the Treasury. The details of this problem are best reserved for discussion at a subsequent meeting of this Society, but it may not be out of place to note that existing hospitals established under provisional orders may require amending orders to meet the new conditions. In Croydon steps have already been taken towards this end. In any case I hope we shall not be led into a futile discussion concernir~g the adjective that will best describe our clinics or dispensaries for the diagnosis and treatment of tuberculosis,
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HEALTH.
Time will be better spent in elaborating comprehensive schemes which should take advantage of all available means for fighting so wide-spread a disease. It is clear that the provision made in the Insurance Bill and the sum allocated in the Budget will enable local sanitary authorities to provide not only resident institutions for the cure, education and supervision of the phthisical, but to equip municipal clinics for selecting suitable patients for the sanatoria, for diagnosing the disease, for undertaking a certain proportion of home treatment, and for the general supervision of all notified cases. But the more complete our organization for the treatment of diagnosable cases becomes, the more clearly will be revealed the necessity for certain auxiliary measures. The relation of the pretuberculous school child to the phthisical adult ; the importance of securing early treatment for adenoids and enlarged tonsils, which are often the portal selected by the tubercle bacillus; the relation of dental defects to malnutrition and of malnutrition to phthisis will become very practical problems where the comprehensive treatment of phthisis is actually undertaken. As the Chancellor of the Exchequer stated in the discussion on the position of deposit contributors, " in dealing with the problem of physical failure they should start with the child." This can, obviously, be effected most conveniently by establishing school clinics, and I suggest that the best way of bring!ng the child within t h e ' a m b i t of the Insurance Bill is to take advantage of the very elastic definition of Sa~mtorb, m Ber~efit, which you will remember includes the treatment (in institutions or otherwise) not only of tuberculosis, but of a n y other diseases which the Local Government Board, with the approval of the Treasury, may appoint. If local authorities were empowered to undertake the treatment of diseases of the nose, throat, ear, eyes, teeth and skin of childran at and below school age the most urgent needs would be met wit.hour interfering to any appreciable extent with domiciliary medical treatment. The cost, of course, would not be a charge on the insurance fund, but shared by the Treasury and local authority. The establishment of school clinics on this basis would have the advantage not only of linking up the school clinic with the future municipal phthisis dispensary, and, to that extent, unifying
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the public medical service, but tile establishment of a clinic for other forms of specialised treatment would ultimately be of service to the insured who will also require treatment of a like nature which will not and cannot be provided by their domiciliary attendant. The municipal clinic would also be available for infant consultations, which are a necessary adjunct to any complete scheme for supervising infant life and for instructing women and girls in the obligations and responsibilities of motherhood. W h e n this extension of the sanatorium is secured, and when the needs of the physically, morally and mentally unfit are met by a reformed poor law, the scope of preventive medicine will be enormously enlarged. Be that as it may, and without building any castles in the air, I hope we shall all fully realise both the opportunities and the responsibilities that are about to be placed on the Public Health service. If this is clone, and if we throw ourselves whole-heartedly into the work, we shall insure not only increased administrative control of disease, but the health and happiness of the next generation. The analysis of sickness returns; the investigation of prima-facie instances of excessive sickness ; the administration of sanatoria, of phthisis dispensaries and of school clinics will all entail much hard work and much clear thinking. But I do not fear that either will be wanting if we appreciate the practical results that will ensue from energy spent in these directions. DISCUSSION. The CHAmMANsaid that after they had heard the Paper it would be felt that with regard to Public Health a new chapter was being opened. In fact a new aspect was going to be the work of prevention of disease, and he felt that the discussion would be fruitful. Dr. E. ~V. Hove (Liverpool), in opening the discussion, expressed the fear that the Society would not be able to influence the Bill in any way, but at the same time they would watch with the closest conceivable interest the progress of what had been described as the opening of a new era in public health. He believed that when the Act had been in operation it would be possible to find out what were the advantages and the disadvantages of the Bill, and the points at which the Bill might be amended. If adequate financial aid was forthcoming there was not the least doubt that the Bill would prove a splendid stimulus to the work of the sanitary authorities. Of course a great many of these bodies would require to be
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stimulated, but, on the other hand, the fact remained that in certain parts of the country the sanitary authorities had not even any by-laws. In some cases the formation of the new Insurance Committees or Health Committees would appear to be unnecessary, but in others he was certain they would be of g r e a t advantage. He agreed with Dr. Richards that it would be a distinct a d v a n t a g e to have on these new committees the chairman and vice-chairman of the Public Health Committees and Hospital Committees and others who were chiefly interested in sanitation. The whole question was one of enormous importance, but he was sure that, whatever the faults of the Bill might be found to be, it would be one of immense value in opening up a vista in preventive medicine and offering facilities for advancement in that direction in the future. Mr. FRE~IANTLE (Herts.), suggested that the insurance companies in this country ought to do as was done by American insurance companies, and assist in taking steps in the direction of preventing sickness. He pointed out that the insurance companies in America had done this from a business point of view and not from any motives of philanthropy. If the English insurance companies were to assist in this work the example which they set would be a good one for the local health committees. As r e g a r d s the clause on excessive sickness amongst the insured, he thought it would be a g r e a t advantage if on the report stage the clause could be enlarged in such a way as to include the dependents of the insured persons. If they had an amendment of that sort it would give them a useful means of going to work with regard tq this clause. He had been interested in the debates in the committee of the House of Commons which'had been .discussing this Bill, which was of g r e a t importance to public health. It was a most extraordinary fact that there had been no expression of opinion of the Local Government Board. The clause was really a bit of window-dressing. A fact which had also struck him was that none of the medical members had taken any p a r t in the debate on this clause. It emphasised a g r e a t point, that was that he could not help feeling that the Society had not organised its forces with r e g a r d to m a k i n g its influence felt in Parliament on a g r e a t scheme of public health. He hoped the Council of the 'Society would take that into consideration, and see what action they could take in that direction. He was sure that their suggestions would be welcomed by Members of Parliament. Mr. GIBBON, in speaking of the sickness and invalidity insurance schemes abroad, said that the sickness societies in Germany had subscribed to numerous tuberculosis dispensaries, and they had distributed literature and given lectures. With regard to the invalidity institutions he said that apart from patients suffering from tuberculosis
IIE.~LTII.
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they also had in these institutions people who suffered from rheumatism, anaemia, and in some cases drunkenness. He declared, however, that the returns which were issued r e g a r d i n g the institutions were not under proper control and were not of much value. The cost of establishing sanatoria had been enormous, and the cost of the maintenance was also high. Including all charges the cost was 6s. per person each day. In these institutions they paid attention to more than mere institutional treatment. A large amount of work was done in assisting other institutions. They had assisted travelling exhibitions, and a m o n g s t other things, especially in H a m b u r g , they had assisted in the treatment of lupus. They had also assisted out of their reserve funds associations for working men to establish dwellings. The establishment of dwellings, of course, was an important part of preventive work, even more so perhaps than the treatment in the institutions. It was proposed by Mr. Fremantle, and seconded by Dr. Ashkenny, that the clause as to exces~slve sickness should be so amended as to include the wives and the other dependents of the insured person. Dr. E. H. SNELL (Coventry), speaking a g a i n s t the proposal, said it was an extension of a principle of the Bill which he thought was a bad one. The health committees would chiefly consist of tl~e members of friendly societies, and in their hands would be placed the duty of criticising sanitary authorities, and there was no provision in the Bill which would put at the disposal of these committees any official who knew anything of sanitary matters. Although the medical officer of health was enabled to attend the meetings of the Health Committee if he was invited, he could onl 'o so by invitation, and therefore he would not be at liberty to go because if he did so he might have to criticise to a certain extent his own actions and advice. If he did so he would be placing himself in a wrong and a false position. It was probable that if there was tiny ill-health in the particular area the committee would be apt t o carp and quibble r e g a r d i n g it. Dr. Snell also pointed out that already too many authorities had to deal with hospital treatment, and the Bill would add one more by creating the local health committees which would take up tuberculosis dispensaries. Dr. R. DUDFIELD (Paddington), referring to remarks made by the previous speaker, said it had been stated in the House that as regards the metropolitan area, instead of having only one Health Committee, each of the twenty-nine sanitary authorities in London would have Health Committees. As regards the excessive sickness clause, whichever way it was looked at they had nothing at the present time which would guide them as to what was the standard of sickness in any district. They had some guide as r e g a r d s the diseases which were notified, but when they came
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to the non-notifiable diseases they had no evidence as to w h a t w a s to be considered a s t a n d a r d . H e t h o u g h t it w a s a m i s t a k e t h a t Clause 46 (the E x cessive S i c k n e s s Clause) should be p u t in o p e r a t i o n at once. I t should have been suspended for five y e a r s to allow the m a t e r i a l to a c c u m u l a t e on which the I n s u r a n c e C o m m i s s i o n e r s would be able to g e t an idea of how t h i n g s would work. T h e Insurance C o m m i s s i o n e r s had g o t practically the position of a S t a r C h a m b e r . H o w far t h a t w a s to be modified he did not know, and it w a s unfortunate t h a t the G o v e r n m e n t had practically refused to accept a n y a m e n d m e n t s which were not their own. H e t h o u g h t himself t h a t it would not be very long before t h e Bill would be in the m e l t i n g pot. Dr. ~VM. BUTLER (X~Villesden) said the b r u n t of the criticism a g a i n s t the Bill had to lie in the fact that it w a s to s u p e r s e d e the e x i s t i n g health authorities. H e t h o u g h t t h a t the Bill had a d v a n t a g e s for outside people, b u t he did not see a n y t h i n g in it which g a v e a n y t h i n g to the medical officers of health. I t w a s a b r e a c h in the p r o g r e s s of public health legislation. It w a s a p r o p e r t h i n g to penalise an a u t h o r i t y which neglected the question of health, b u t at the s a m e time it w a s p r a c t i c a l l y impossible to p u t down excessive sickness to adm i n i s t r a t i o n or r e a l - a d m i n i s t r a t i o n on account of the causes from which a disease m i g h t arise. SURGEON-GENERAL E VATT, C.B., e x p r e s s e d the view t h a t w h e n the t r e m e n d o u s e x p e n s e of maint a i n i n g sick people c a m e on the country the students would be forced to t a k e out a d i p l o m a of public health, and the medical officer of health would be compelled to g o back a g a i n to postg r a d u a t e training. D.. ~RANDLEHARPER r e m a r k e d that he was present in the H o u s e of C o m m o n s on W e d n e s d a y evening, and he h e a r d the Chancellor of the E x c h e q u e r i n t i m a t e t h a t h e expected the medical omcer of h e a l t h w o u l d a t t e n d the m e e t i n g of his own c o m m i t t e e and also the m e e t i n g of the Local I t e a l t h Committee. Dr. HERBERT JONES (Hon. See.), in s p e a k i n g of Clause 46 , s u g g e s t e d t h a t the previous s p e a k e r s had not t a k e n into account the rural areas. He a p p r e h e n d e d t h a t Clause 46 was chiefly a i m e d at these areas. I t w a s quite impossible, if it w a s r e m e m b e r e d t h a t a l m o s t every w e e k r e p o r t s were issued from the ,Local G o v e r n m e n t B o a r d respecti n g rural areas, to feel t h a t steps were not necessary in r e g a r d to these areas. A t p r e s e n t the only w a y in which m a n y authorities could be b r o u g h t to do w h a t they o u g h t to do w a s by m a n d a m u s , and t h a t w a s absolutely impossible as a w e a p o n to use. T h e u r b a n a r e a s h a d their bylaws and r e g u l a t i o n s , and they had a d o p t e d Acts, hut there w e r e scores and scores of rural districts in which the a u t h o r i t y had not a d o p t e d any r e g u lations at all or any by-laws. I t w a s essential
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t h a t s o m e t h i n g should be d o n e to g e t these authorities to do w h a t they o u g h t to do, and it w a s t h e r e t h a t the usefulness of this clause w o u l d c o m e in if it w a s allowed to r e m a i n in the Act. T h e m e r e t h r e a t of a medical officer of h e a l t h t h a t he would be entitled to p u t this clause in force w o u l d be a l m o s t e n o u g h to g e t done t h a t which he required. In connection with this clause it would be necess a r y t h a t a medical officer of health should have security of tenure. Dr. J. HOWARD JONES (Newport) a p p e a l e d to the Council to consider the m a t t e r which t h e y had been discussing, especially in r e g a r d to how it w a s g o i n g to affect the medical officers of health, as to how it would be possible for t h e m to e d u c a t e the public health c o m m i t t e e s as to the p o s i t i o n of the medical officer, and as to h o w t h e c o m m i t t e e s could be m a d e i n s t r u m e n t s to s t r e n g t h e n t h a t position. Dr. ASHKENNY (Ilford) also said it w a s t h e duty of the Society to m a k e their influence felt as a d v i s e r s in m a t t e r s of public health. H e believed t h a t P a r l i a m e n t w a s w a t c h i n g them, and P a r l i a m e n t m u s t notice how l a c k a d a i s i c a l they h a d been in r e g a r d to m a k i n g r e c o m m e n d a t i o n s . He s u p p o r t e d the p r o p o s i t i o n p u t f o r w a r d b y Dr. F r e m a n t l e because from their p o i n t of view half a loaf w a s better t h a n no bread. H e h a r d l y expected it would be possible for them to m a k e such a d r a s t i c a l t e r a t i o n in the Bill, and he would be g l a d if they g o t this a m e n d m e n t . Mr. MONTAGUE HARRIS,of the C o u n t y C o u n c i l s ' Association, e x p r e s s e d the view t h a t an effect of the Bill would be to confer upon C o u n t y Councils w i d e r p o w e r s as public health authorities. In r e g a r d to g e t t i n g the p o w e r s in full effect the A s s o c i a t i o n were m o s t anxious to have the assistance of the county medical officers, a n d their advice in this m a t t e r , especially in r e g a r d to the w a y in which the Bill w a s to be a d m i n i s t e r e d . U p to the p r e s e n t the Association had succeeded in g e t t i n g the Bill altered in such a w a y as to r e m o v e some of the difficulties which they first saw in it, and they would be g l a d to p u t f o r w a r d any s u g g e s t i o n s which the medical officers m i g h t t h i n k fit. A m o n g the points which the), wished to p u t f o r w a r d still were as r e g a r d s the issue of r e p o r t s from the I n s u r a n c e C o m m i s s i o n e r s to the local authorities, and also as to the position of medical officers in relation to H e a l t h Committees. T h e CHAIRMAN a g r e e d with Dr. H e r b e r t Jones t h a t the rural a r e a s would be chiefly affected by Clause 46 . H e did not t h i n k it would be a d a n g e r o u s clause, because after a c o m p l a i n t w a s m a d e an enquiry would have to be held by a medical man, and before a n y t h i n g could be done to penalise the district the medical m a n would have to be satisfied t h a t the evidence w a s sufficient for p e n a l i s i n g to be done. T h e Bill w a s g o i n g to be valuable, if n o t h i n g else, for e d u c a t i n g the public as to how disease could be prevented.
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Dr. H. M. RICHARDS,in replying on the discussion, suggested that as regards Parliamentary influence they ought to take a leaf out of the book of the Municipal and County Councils Associations. If they could induce one or two members on either side of the House to interest themselves in their work it would be most valuable, and would enable them to obtain adequate expression of their views in public health legislation. As regards the analysis of statistics, he believed that work should be supervised and co-ordinated by the Registrar-General. As regard~ what Dr. Snell said, if the Bill went through in its present form he should ask his Council to give him a perfectly free hand to make any recommendation he thought fit in the Insurance Committees. Unless he got that permission he would not be at liberty to advise the Insurance Committee. Referring to remarks by Dr. Howard Jones, he said the way to get over the trouble in Wales was to make the \Velsh Memorial Association responsible for the curative sanatoria for the treatment of early cases. The meeting agreed to suspend the Standing Orders, and the vote being taken on the proposition of Mr. Fremantte, it was lost by a large majority. It was moved by Dr. Riehards, and seconded by Dr. Symons, of Bath, that a communication be addressed to the Chancellor of the Exchequer thanking him for his proposal to assist local authorities in dealing with physical defects of children. The proposal was carried unanimously. A proposal was also submitted by Dr. Herbert Jones to send a communication to the Chancellor of the Exchequer to urge upon him the necessity for giving security of tenure to district medical officers in view of the provisions of Clause 4 6 . The proposition was seconded by Dr. Symons, and carried, with one dissentient. On tile suggestion of the President a subcommittee was appointed, consisting of the President, Dr. H. Meredith Richards, Dr. \V. G. YVilloughby and Dr. YVm. Butler, to draft proposals arising out of the discussion for transmission to the Chancellor of the Exchequer, such committee being empowered to act on behalf of the Society. A COUNTY BACTERIOLOGICAL LABORATORY FOR HAMPSHIRE.--The H a m p s h i r e County Council have decided to establish a county bacteriological laboratory, under the charge of the county medical officer of health. T h e cost of establishing the laboratory is estimated at ~25o , and the annual expenditure at L3co. At the present time the county cot!nell are expending ~ 2 i i a year on bacteriologi'cal work, and the district councils are expending ~24o, making a total expenditure of ~45o a year, or 5 ° per cent more than the estimated annual cost of the proposed laboratory.
DECEMBER,
THE PRESENT POSITION OF.THE PUBLIC HEALTH MEDICAL SERVICE.* BY HENRY
HANDFORD,
M.D.,
F.R.C.P.,
D.P.H.,
Consulting Physician to the General Hospital, Nottingham, and to the NOttingham and Notts. Sanatorium fo r Consumption, County Medical Officer for Nottinghamshire. the first place allow m e to t h a n k the I N Society for electing m e to fill this h o n o u r able office, Society to endeavour interests of
a n d in the next m a y I ask tile a c c e p t m y a s s u r a n c e t h a t I will so far as I can to p r o m o t e t h e the Society and m a k e the Session
a success.
P r e v e n t i v e medicine is one of the y o u n g e r b r a n c h e s of medical science a n d practice, at a n y r a t e so far as can be j u d g e d by its official recognition, A l t h o u g h the influence of t h e d o c t o r was recognised as beneficial to t h e community, as well as to t h e individual, in H o m e r i c t i m e s and in the early h i s t o r y of E g y p t , such influence sank to n o t h i n g in t h e Middle Ages a n d i m p r o v e d but slightly with the revival of learning which a c c o m p a n i e d t h e R e n a i s s a n c e . It was not, in this country, utatil the 'seventies t h a t public health and p r e v e n t i v e medicine received general public recognition and m a d e a n y effective start. I t is true t h a t the T o w n s h n p r o v e m e n t Clauses Act of 1847 gave power, with m a n y restrictions, to a p p o i n t a salaried "officer of h e a l t h . " T h i s w a s followed b y t h e Public H e a l t h Act of 1848, which was only an " adoptive" Act, and various m i n o r acts, including the N u i s a n c e s R e m o v a l Act, 186o. Dr. Duncan, of Liverpool, was the first medical officer of health, and was a p p o i n t e d under a L o c a l Act in 1847. I t was not until the Public H e a l t h Act of 1872 w a s passed, t h a t the d u t y of a p p o i n t i n g medical officers of health was i m p o s e d upon t h e local authorities in all p a r t s of E n g l a n d and W a l e s outside the metropolis. T h e Act of 1872 divided the whole of E n g l a n d a n d W a l e s , exclusive of the m e t r o polis,into " U r b a n S a n i t a r y Districts and R u r a l S a n i t a r y Districts," as t h e y are now known. All these Acts, and several others, w e r e consolidated in the Public H e a l t h Act of 1875, u n d e r which m o s t of the public health w o r k of the present d a y is still done, t h o u g h there have been several a m e n d i n g Acts, and m a n y " a d o p t i v e " Acts since t h a t time. I t is of s o m e interest, therefore, to the m e m b e r s of the public health service, as well * Presidential Address delivered to the Midland Branch of the Society of Medical Officers of Health, October 5th, I9Ix.
NO T E . - - C l a u s e s 43 to 47, dealing with Local ttealth Committees, Excessive Sickness and the Provision of Sanatoria will be discussed in Parliament while this paper is in the printer's hands. For the moment it is assumed that (subject to the Government amendments) these clauses will be passed in their present form. introducing this discussion I shall conI N fine myself as closely as possible to the broader Public Health aspects of the Insurance Bill, which I am assuming will pass into law without any substantial change, other than what is contained in the various amendments that have been proposed or accepted by the Government. It is to be hoped that we shall refrain for the moment from discussing alternative schemes. To do so at this juncture would serve no useful purpose and tend to divert oui discussion from pressing practical problems. Similarly I propose, on this occasion, to put on one side such interesting topics as the prevention of malingering; the contributions to be paid and the benefits to be received by various classes of insured persons, together with the whole problem of domiciliary medical attendance. The last subject has already been adequately discussed by other medical societies, and personally I have little to add to the suggested scheme which has been published in the " Lancet " and elsewhere. The National Insurance Bill is intended " to provide for insurance against loss of health and for the prevention and cure of sickness." Its purpose is therefore two-fold, viz. : (I) to provide material aid in time of sickness, and (2) to prevent and cure disease. Obviously the latter object is, in the main, the more important, and hence the necessity for enquiring how it can be most completely achieved. Clearly an insurance scheme in which the underwriters calculated their premiums according to past experience, and did not interest themselves in diminishing future risks would have no preventive value. As a matter of fact this attitude of detachment is not a necessary part of ordinary commercial insurance. In
DECEMBER,
some instances (for example, policies covering the risk of a wet Coronation week) underwriters neither do nor can take any steps to diminish the risks against which they insure. In marine and fire insurance the conditions are for the most part quite different. The shipowner who wishes to insure a steamer at ordinary rates has to produce evidence that the vessel is pr6perly constructed, and to submit his vessel to a stringent periodical inspection by Lloyds' surveyors. Similarly fire insurance offices will not insure premises that are built of inflammable materials except at high premiums, and insist that special precautions shall be taken in respect to dangerous trades. In this way insurance does indirectly stimulate prevention by offering substantial financial advantages to those who adopt all available precautions. This will apply to sickness insurance. Societies which desire to build up reserves and to reduce their average duration of sick pay will have every inducement to press for greater efficiency it~ respect to the Medical and Sanatorium benefits, and to regard the activities of sanitary authorities with enlightened self-interest. They will, in fact, stand to gain as much from a preventive medical service as Fire Insurance Corporations gain from the public provision of fire extinguishing appliances, and, by their representation on the Insurance Committees, be in a very favourable position for giving effect to their wishes. In practice it is probable that the immediate effect of the Insurance Scheme on preventive medicine will be proportional to the initial bias of the new Insurance Committees, and to the extent to which their work is harmoniously co-ordinated with existing Public Health organisations. The constitution and duties of the new committees therefore require careful consideration. Tile committees will be appointed for every County and County Borough, and will consist of a nucleus of twenty-four to forty-eight members, to which the County and Borough Councils with the Insurance Commissioners will add two-thirds. The members will be appointed as follows :--Nominated by County or Borough Council ............ 8* or I6" Nominated by Insured persons ... 24 or 4 8 (proportion representing approved Societies to be settled by the Commissioners)
Medical practitioners appointed by those in practice in the district ........................... "~ T w o o f w h o m n l u s t 'be w o m e n ,
2
2
PUBLIC HEALTH.
1911. Medical practitioners appointed by the Insurance Commissioners ........................ Other persons ap'pointed by the Insurance Commissioners ...
1 5" or
i 13"
Total 4 ° or 8o There is also a proviso that the proportion nominated by County and Borough Councils may be increased if the County or Borough undertake any financial liability. In county areas it is intended to set up local Insurance Committees in the larger urban districts. It is to be hoped that those who are responsible for these appointments will realize how imperative it is that the best available representatives should be selected. In most districts it would be an advantage if the chairman and, or, vice-chairman of the Public Health and Hospitals Committees of the C o u n t y or Borough Council, and the chairman or vicechairman of the Medical Inspection Committee of the Education Committee were a m o n g those nominated to represent the County and Borough Councils. The duties of the new Insurance Committees include : - (I) Administration of Medical Benefit. With this I do not propose to deal for reasons already given.
(2) Administration of Sanatorium Benefit. This will be one of the most important functions of the committee, and can be more conveniently discussed at a later stage. (3) A,dministration of Sickness, Disable-
ment and Maternity Benefit in respect of Deposit Contributors. The amount of work involved in administering the benefits of the Post Office group will vary in different districts. To a large extent the actual administration will be settled by the scheme, but a very important function of the committee will consist in accumulating facts and in making suggestions in respect to what is, at present, a provisional and transitory part of the national scheme. (4) The amendment agreed with the re-
presentatives of County Councils and Corporations provides that the new committee " shall make such reports as t o the health of insured persons within the County or County Borough as the Insurance Commissioners, after consultation w i t h the Local Government Board, m a y prescribe, and shall furnish to them such statistical affd other returns as they may require, and may make such other reports * Two
Of w h 0 r n
must
b e WOtllel~.
~3
on the health of such persons, and the conditions affecting the same, and may make such suggestions with regard thereto as it may think fit, and the Insurance Commissioners shall forward to tlfe Councils of the Counties, County Boroughs, and County Districts, which appear to them to be affected by or interested in a n y such reports, returns, or suggestions, copies of such reports, returns, and suggestions." This is a most important duty of the committee which will require much expert knowledge and administrative skill if the central and local authorities are to have the information in a form which they can assimilate and use for practical ends. It is difficult to see how this can be effected unless the Committee has at its disposal a medical expert. It is true that it is proposed that the County, Borough or District medical officer of health may attend the committee, but he could hardly undertake the onerous duty of collating and analysing these statistics unless it were made incumbent on him by statute or by order of the Local Government Board. I suggest that the sickness returns should be furnished to the medical officer of health at weekly or monthly intervals, and that the Local Government Board should make it obligatory for the medical officer of health to report thereon to the Insurance Commissioners, Local Government Board, and to the locaI authority concerned, if the co-operation of the Registrar General is obtained, it would be possible to secure a uniform system of classification and to insure that sickness and death returns are, as far as possible, comparable. Such an arrangement would have m a n y advantages. County and Borough Councils could not object to their medical officer of health carrying out a statutory duty or to an)" necessary augmentation of his clerical staff. Recommendations arising out of the sickness returns would be more promptly dealt with, and with less danger of friction, if they arose on the independent report of the medical officer of health than if they were received in an undigested form from the Insurance Committee. The medical officer of health would be furnished with a solid basis of fact whereon to base recommendations for sanitary progress. As I have already shown elsewhere it is probable that one of the most important iesults that the Insurance scheme will bring about is the classification of the insured. Most of the difficulties of our public health and
8~
PUBLIC HEALTH.
social problems are due to their complexity, and these difficulties will be considerably lightened if we can classify the population according to the healthiness or otherwise of their occupations, the part l~layed b y economic pressure in producing physical inefficiency and the results of intemperance and idleness. Thus the deposit contributors will eventually include (a) the physically defective ; (b) those who have been expelled from the Friendly Societies I~hrough misconduct; (c) those who have run out of benefit through idleness or through lack of employment. All this classification will be invaluable not merely for the purposes of the Insurance Bill but for laying the foundation whereon a reformed poor law must be built. On the other hand the classification will be unreliable and valueless unless the figures have been analysed b y someone who has not merely some mathematical training but is versed in the natural history of disease. (5) Excessive Sickness. The next duty of the new committee will be to make claims in respect to excessive sickness due to employment, housing, sanitary conditions, contaminated water supply or neglect of the Public Health and Factories Acts. Now the causes of sickness are so complex that it does not seem likely that claims will often be made good except in the comparatively simple cases of unhealthy occupations and of water epidemics. Obviously there is nothing inequitable in making an unhealthy trade bear its own burden, or in making a water authority responsible for supplying contaminated water. In other instances the knowledge that neglect of sanitary provisions may lead to financial liabilities is likely to stimulate the hygienic conscience even if claims for excessive sickness are seldom brought home. In any case immediate enquiry into the causes of actual or apparent excessive sickness should be a primary duty of the medical officer of health. I now come to the administration of Sanatorium benefit, i.e., Treatment in sanatoria or other institutions or otherwise when suffering from tuberculosis or such other diseases as the Local Government Board w~th the approval of the Treasury may appoint. In the Chancellor's most recent explanatory Memorandum (Cd. 5930, P. 2), it is stated that sanatorium treatment will be extended to wives, children, and dependants of insured persons, and " that the Treasury would make itself responsible to the extent of one-half for
DEam3Ea,
any expenditure u p o n such treatment which might not be covered b y the money available under the Bill, provided the persons or local authorities giving tile treatment make themselves responsible for the other half. Sanatorium treatment will be administered by the existing local health authorities or such other persons as may be approved b y the Local Government Board, and provided that they pay one-half of any cost in excess of tl!e amount provided b y the National hasurance Fund, the Treasury will undertake to pay the other half." It is not clear whether it is intended to make use of Poor Law institutions for the institutional treatment of the insured and of their dependants. From the Times report of the debate on Clause 47 it would appear that this point is reserved. I suggest that this Society might usefully point out the inadvisability of relegating any part of the contemplated treatment of phthisis to Poor Law authorities. Otherwise in certain districts we shall have overlapping, while in other districts we shall see Guardians and Borough Councils engaged in the familiar pastime of disclaiming responsibility for meeting the public needs. The treatment of phthisis should be made a Public Health obligation. Public Health authorities should also be given the power to initiate the extension of sanatorium benefit to the dependants of the insured and to deposit contributors who have run out of benefit. At present this extension is dependent on the action of the Insurance Committees, who m a y or may not be progressive bodies. The immense impetus that this will give not only to the provision of sanatoria but to other specialised methods both for detecting and for treating phthisis is obvious. As soon as the Insurance Bill becomes law local authorities will need advice as to the best way in which they can meet the needs of th~ insured and take advantage of the opportunity afforded b y the Treasury. The details of this problem are best reserved for discussion at a subsequent meeting of this Society, but it may not be out of place to note that existing hospitals established under provisional orders may require amending orders to meet the new conditions. In Croydon steps have already been taken towards this end. In any case I hope we shall not be led into a futile discussion concernir~g the adjective that will best describe our clinics or dispensaries for the diagnosis and treatment of tuberculosis,
1911.
PUBLIC
HEALTH.
Time will be better spent in elaborating comprehensive schemes which should take advantage of all available means for fighting so wide-spread a disease. It is clear that the provision made in the Insurance Bill and the sum allocated in the Budget will enable local sanitary authorities to provide not only resident institutions for the cure, education and supervision of the phthisical, but to equip municipal clinics for selecting suitable patients for the sanatoria, for diagnosing the disease, for undertaking a certain proportion of home treatment, and for the general supervision of all notified cases. But the more complete our organization for the treatment of diagnosable cases becomes, the more clearly will be revealed the necessity for certain auxiliary measures. The relation of the pretuberculous school child to the phthisical adult ; the importance of securing early treatment for adenoids and enlarged tonsils, which are often the portal selected by the tubercle bacillus; the relation of dental defects to malnutrition and of malnutrition to phthisis will become very practical problems where the comprehensive treatment of phthisis is actually undertaken. As the Chancellor of the Exchequer stated in the discussion on the position of deposit contributors, " in dealing with the problem of physical failure they should start with the child." This can, obviously, be effected most conveniently by establishing school clinics, and I suggest that the best way of bring!ng the child within t h e ' a m b i t of the Insurance Bill is to take advantage of the very elastic definition of Sa~mtorb, m Ber~efit, which you will remember includes the treatment (in institutions or otherwise) not only of tuberculosis, but of a n y other diseases which the Local Government Board, with the approval of the Treasury, may appoint. If local authorities were empowered to undertake the treatment of diseases of the nose, throat, ear, eyes, teeth and skin of childran at and below school age the most urgent needs would be met wit.hour interfering to any appreciable extent with domiciliary medical treatment. The cost, of course, would not be a charge on the insurance fund, but shared by the Treasury and local authority. The establishment of school clinics on this basis would have the advantage not only of linking up the school clinic with the future municipal phthisis dispensary, and, to that extent, unifying
i
I
8b
the public medical service, but tile establishment of a clinic for other forms of specialised treatment would ultimately be of service to the insured who will also require treatment of a like nature which will not and cannot be provided by their domiciliary attendant. The municipal clinic would also be available for infant consultations, which are a necessary adjunct to any complete scheme for supervising infant life and for instructing women and girls in the obligations and responsibilities of motherhood. W h e n this extension of the sanatorium is secured, and when the needs of the physically, morally and mentally unfit are met by a reformed poor law, the scope of preventive medicine will be enormously enlarged. Be that as it may, and without building any castles in the air, I hope we shall all fully realise both the opportunities and the responsibilities that are about to be placed on the Public Health service. If this is clone, and if we throw ourselves whole-heartedly into the work, we shall insure not only increased administrative control of disease, but the health and happiness of the next generation. The analysis of sickness returns; the investigation of prima-facie instances of excessive sickness ; the administration of sanatoria, of phthisis dispensaries and of school clinics will all entail much hard work and much clear thinking. But I do not fear that either will be wanting if we appreciate the practical results that will ensue from energy spent in these directions. DISCUSSION. The CHAmMANsaid that after they had heard the Paper it would be felt that with regard to Public Health a new chapter was being opened. In fact a new aspect was going to be the work of prevention of disease, and he felt that the discussion would be fruitful. Dr. E. ~V. Hove (Liverpool), in opening the discussion, expressed the fear that the Society would not be able to influence the Bill in any way, but at the same time they would watch with the closest conceivable interest the progress of what had been described as the opening of a new era in public health. He believed that when the Act had been in operation it would be possible to find out what were the advantages and the disadvantages of the Bill, and the points at which the Bill might be amended. If adequate financial aid was forthcoming there was not the least doubt that the Bill would prove a splendid stimulus to the work of the sanitary authorities. Of course a great many of these bodies would require to be
86
PUBLIC
stimulated, but, on the other hand, the fact remained that in certain parts of the country the sanitary authorities had not even any by-laws. In some cases the formation of the new Insurance Committees or Health Committees would appear to be unnecessary, but in others he was certain they would be of g r e a t advantage. He agreed with Dr. Richards that it would be a distinct a d v a n t a g e to have on these new committees the chairman and vice-chairman of the Public Health Committees and Hospital Committees and others who were chiefly interested in sanitation. The whole question was one of enormous importance, but he was sure that, whatever the faults of the Bill might be found to be, it would be one of immense value in opening up a vista in preventive medicine and offering facilities for advancement in that direction in the future. Mr. FRE~IANTLE (Herts.), suggested that the insurance companies in this country ought to do as was done by American insurance companies, and assist in taking steps in the direction of preventing sickness. He pointed out that the insurance companies in America had done this from a business point of view and not from any motives of philanthropy. If the English insurance companies were to assist in this work the example which they set would be a good one for the local health committees. As r e g a r d s the clause on excessive sickness amongst the insured, he thought it would be a g r e a t advantage if on the report stage the clause could be enlarged in such a way as to include the dependents of the insured persons. If they had an amendment of that sort it would give them a useful means of going to work with regard tq this clause. He had been interested in the debates in the committee of the House of Commons which'had been .discussing this Bill, which was of g r e a t importance to public health. It was a most extraordinary fact that there had been no expression of opinion of the Local Government Board. The clause was really a bit of window-dressing. A fact which had also struck him was that none of the medical members had taken any p a r t in the debate on this clause. It emphasised a g r e a t point, that was that he could not help feeling that the Society had not organised its forces with r e g a r d to m a k i n g its influence felt in Parliament on a g r e a t scheme of public health. He hoped the Council of the 'Society would take that into consideration, and see what action they could take in that direction. He was sure that their suggestions would be welcomed by Members of Parliament. Mr. GIBBON, in speaking of the sickness and invalidity insurance schemes abroad, said that the sickness societies in Germany had subscribed to numerous tuberculosis dispensaries, and they had distributed literature and given lectures. With regard to the invalidity institutions he said that apart from patients suffering from tuberculosis
IIE.~LTII.
DECemBER,
they also had in these institutions people who suffered from rheumatism, anaemia, and in some cases drunkenness. He declared, however, that the returns which were issued r e g a r d i n g the institutions were not under proper control and were not of much value. The cost of establishing sanatoria had been enormous, and the cost of the maintenance was also high. Including all charges the cost was 6s. per person each day. In these institutions they paid attention to more than mere institutional treatment. A large amount of work was done in assisting other institutions. They had assisted travelling exhibitions, and a m o n g s t other things, especially in H a m b u r g , they had assisted in the treatment of lupus. They had also assisted out of their reserve funds associations for working men to establish dwellings. The establishment of dwellings, of course, was an important part of preventive work, even more so perhaps than the treatment in the institutions. It was proposed by Mr. Fremantle, and seconded by Dr. Ashkenny, that the clause as to exces~slve sickness should be so amended as to include the wives and the other dependents of the insured person. Dr. E. H. SNELL (Coventry), speaking a g a i n s t the proposal, said it was an extension of a principle of the Bill which he thought was a bad one. The health committees would chiefly consist of tl~e members of friendly societies, and in their hands would be placed the duty of criticising sanitary authorities, and there was no provision in the Bill which would put at the disposal of these committees any official who knew anything of sanitary matters. Although the medical officer of health was enabled to attend the meetings of the Health Committee if he was invited, he could onl 'o so by invitation, and therefore he would not be at liberty to go because if he did so he might have to criticise to a certain extent his own actions and advice. If he did so he would be placing himself in a wrong and a false position. It was probable that if there was tiny ill-health in the particular area the committee would be apt t o carp and quibble r e g a r d i n g it. Dr. Snell also pointed out that already too many authorities had to deal with hospital treatment, and the Bill would add one more by creating the local health committees which would take up tuberculosis dispensaries. Dr. R. DUDFIELD (Paddington), referring to remarks made by the previous speaker, said it had been stated in the House that as regards the metropolitan area, instead of having only one Health Committee, each of the twenty-nine sanitary authorities in London would have Health Committees. As regards the excessive sickness clause, whichever way it was looked at they had nothing at the present time which would guide them as to what was the standard of sickness in any district. They had some guide as r e g a r d s the diseases which were notified, but when they came
1911.
PUBLIC
to the non-notifiable diseases they had no evidence as to w h a t w a s to be considered a s t a n d a r d . H e t h o u g h t it w a s a m i s t a k e t h a t Clause 46 (the E x cessive S i c k n e s s Clause) should be p u t in o p e r a t i o n at once. I t should have been suspended for five y e a r s to allow the m a t e r i a l to a c c u m u l a t e on which the I n s u r a n c e C o m m i s s i o n e r s would be able to g e t an idea of how t h i n g s would work. T h e Insurance C o m m i s s i o n e r s had g o t practically the position of a S t a r C h a m b e r . H o w far t h a t w a s to be modified he did not know, and it w a s unfortunate t h a t the G o v e r n m e n t had practically refused to accept a n y a m e n d m e n t s which were not their own. H e t h o u g h t himself t h a t it would not be very long before t h e Bill would be in the m e l t i n g pot. Dr. ~VM. BUTLER (X~Villesden) said the b r u n t of the criticism a g a i n s t the Bill had to lie in the fact that it w a s to s u p e r s e d e the e x i s t i n g health authorities. H e t h o u g h t t h a t the Bill had a d v a n t a g e s for outside people, b u t he did not see a n y t h i n g in it which g a v e a n y t h i n g to the medical officers of health. I t w a s a b r e a c h in the p r o g r e s s of public health legislation. It w a s a p r o p e r t h i n g to penalise an a u t h o r i t y which neglected the question of health, b u t at the s a m e time it w a s p r a c t i c a l l y impossible to p u t down excessive sickness to adm i n i s t r a t i o n or r e a l - a d m i n i s t r a t i o n on account of the causes from which a disease m i g h t arise. SURGEON-GENERAL E VATT, C.B., e x p r e s s e d the view t h a t w h e n the t r e m e n d o u s e x p e n s e of maint a i n i n g sick people c a m e on the country the students would be forced to t a k e out a d i p l o m a of public health, and the medical officer of health would be compelled to g o back a g a i n to postg r a d u a t e training. D.. ~RANDLEHARPER r e m a r k e d that he was present in the H o u s e of C o m m o n s on W e d n e s d a y evening, and he h e a r d the Chancellor of the E x c h e q u e r i n t i m a t e t h a t h e expected the medical omcer of h e a l t h w o u l d a t t e n d the m e e t i n g of his own c o m m i t t e e and also the m e e t i n g of the Local I t e a l t h Committee. Dr. HERBERT JONES (Hon. See.), in s p e a k i n g of Clause 46 , s u g g e s t e d t h a t the previous s p e a k e r s had not t a k e n into account the rural areas. He a p p r e h e n d e d t h a t Clause 46 was chiefly a i m e d at these areas. I t w a s quite impossible, if it w a s r e m e m b e r e d t h a t a l m o s t every w e e k r e p o r t s were issued from the ,Local G o v e r n m e n t B o a r d respecti n g rural areas, to feel t h a t steps were not necessary in r e g a r d to these areas. A t p r e s e n t the only w a y in which m a n y authorities could be b r o u g h t to do w h a t they o u g h t to do w a s by m a n d a m u s , and t h a t w a s absolutely impossible as a w e a p o n to use. T h e u r b a n a r e a s h a d their bylaws and r e g u l a t i o n s , and they had a d o p t e d Acts, hut there w e r e scores and scores of rural districts in which the a u t h o r i t y had not a d o p t e d any r e g u lations at all or any by-laws. I t w a s essential
HEALTH.
87
t h a t s o m e t h i n g should be d o n e to g e t these authorities to do w h a t they o u g h t to do, and it w a s t h e r e t h a t the usefulness of this clause w o u l d c o m e in if it w a s allowed to r e m a i n in the Act. T h e m e r e t h r e a t of a medical officer of h e a l t h t h a t he would be entitled to p u t this clause in force w o u l d be a l m o s t e n o u g h to g e t done t h a t which he required. In connection with this clause it would be necess a r y t h a t a medical officer of health should have security of tenure. Dr. J. HOWARD JONES (Newport) a p p e a l e d to the Council to consider the m a t t e r which t h e y had been discussing, especially in r e g a r d to how it w a s g o i n g to affect the medical officers of health, as to how it would be possible for t h e m to e d u c a t e the public health c o m m i t t e e s as to the p o s i t i o n of the medical officer, and as to h o w t h e c o m m i t t e e s could be m a d e i n s t r u m e n t s to s t r e n g t h e n t h a t position. Dr. ASHKENNY (Ilford) also said it w a s t h e duty of the Society to m a k e their influence felt as a d v i s e r s in m a t t e r s of public health. H e believed t h a t P a r l i a m e n t w a s w a t c h i n g them, and P a r l i a m e n t m u s t notice how l a c k a d a i s i c a l they h a d been in r e g a r d to m a k i n g r e c o m m e n d a t i o n s . He s u p p o r t e d the p r o p o s i t i o n p u t f o r w a r d b y Dr. F r e m a n t l e because from their p o i n t of view half a loaf w a s better t h a n no bread. H e h a r d l y expected it would be possible for them to m a k e such a d r a s t i c a l t e r a t i o n in the Bill, and he would be g l a d if they g o t this a m e n d m e n t . Mr. MONTAGUE HARRIS,of the C o u n t y C o u n c i l s ' Association, e x p r e s s e d the view t h a t an effect of the Bill would be to confer upon C o u n t y Councils w i d e r p o w e r s as public health authorities. In r e g a r d to g e t t i n g the p o w e r s in full effect the A s s o c i a t i o n were m o s t anxious to have the assistance of the county medical officers, a n d their advice in this m a t t e r , especially in r e g a r d to the w a y in which the Bill w a s to be a d m i n i s t e r e d . U p to the p r e s e n t the Association had succeeded in g e t t i n g the Bill altered in such a w a y as to r e m o v e some of the difficulties which they first saw in it, and they would be g l a d to p u t f o r w a r d any s u g g e s t i o n s which the medical officers m i g h t t h i n k fit. A m o n g the points which the), wished to p u t f o r w a r d still were as r e g a r d s the issue of r e p o r t s from the I n s u r a n c e C o m m i s s i o n e r s to the local authorities, and also as to the position of medical officers in relation to H e a l t h Committees. T h e CHAIRMAN a g r e e d with Dr. H e r b e r t Jones t h a t the rural a r e a s would be chiefly affected by Clause 46 . H e did not t h i n k it would be a d a n g e r o u s clause, because after a c o m p l a i n t w a s m a d e an enquiry would have to be held by a medical man, and before a n y t h i n g could be done to penalise the district the medical m a n would have to be satisfied t h a t the evidence w a s sufficient for p e n a l i s i n g to be done. T h e Bill w a s g o i n g to be valuable, if n o t h i n g else, for e d u c a t i n g the public as to how disease could be prevented.
88
PUBLIC HEALTH.
Dr. H. M. RICHARDS,in replying on the discussion, suggested that as regards Parliamentary influence they ought to take a leaf out of the book of the Municipal and County Councils Associations. If they could induce one or two members on either side of the House to interest themselves in their work it would be most valuable, and would enable them to obtain adequate expression of their views in public health legislation. As regards the analysis of statistics, he believed that work should be supervised and co-ordinated by the Registrar-General. As regard~ what Dr. Snell said, if the Bill went through in its present form he should ask his Council to give him a perfectly free hand to make any recommendation he thought fit in the Insurance Committees. Unless he got that permission he would not be at liberty to advise the Insurance Committee. Referring to remarks by Dr. Howard Jones, he said the way to get over the trouble in Wales was to make the \Velsh Memorial Association responsible for the curative sanatoria for the treatment of early cases. The meeting agreed to suspend the Standing Orders, and the vote being taken on the proposition of Mr. Fremantte, it was lost by a large majority. It was moved by Dr. Riehards, and seconded by Dr. Symons, of Bath, that a communication be addressed to the Chancellor of the Exchequer thanking him for his proposal to assist local authorities in dealing with physical defects of children. The proposal was carried unanimously. A proposal was also submitted by Dr. Herbert Jones to send a communication to the Chancellor of the Exchequer to urge upon him the necessity for giving security of tenure to district medical officers in view of the provisions of Clause 4 6 . The proposition was seconded by Dr. Symons, and carried, with one dissentient. On tile suggestion of the President a subcommittee was appointed, consisting of the President, Dr. H. Meredith Richards, Dr. \V. G. YVilloughby and Dr. YVm. Butler, to draft proposals arising out of the discussion for transmission to the Chancellor of the Exchequer, such committee being empowered to act on behalf of the Society. A COUNTY BACTERIOLOGICAL LABORATORY FOR HAMPSHIRE.--The H a m p s h i r e County Council have decided to establish a county bacteriological laboratory, under the charge of the county medical officer of health. T h e cost of establishing the laboratory is estimated at ~25o , and the annual expenditure at L3co. At the present time the county cot!nell are expending ~ 2 i i a year on bacteriologi'cal work, and the district councils are expending ~24o, making a total expenditure of ~45o a year, or 5 ° per cent more than the estimated annual cost of the proposed laboratory.
DECEMBER,
THE PRESENT POSITION OF.THE PUBLIC HEALTH MEDICAL SERVICE.* BY HENRY
HANDFORD,
M.D.,
F.R.C.P.,
D.P.H.,
Consulting Physician to the General Hospital, Nottingham, and to the NOttingham and Notts. Sanatorium fo r Consumption, County Medical Officer for Nottinghamshire. the first place allow m e to t h a n k the I N Society for electing m e to fill this h o n o u r able office, Society to endeavour interests of
a n d in the next m a y I ask tile a c c e p t m y a s s u r a n c e t h a t I will so far as I can to p r o m o t e t h e the Society and m a k e the Session
a success.
P r e v e n t i v e medicine is one of the y o u n g e r b r a n c h e s of medical science a n d practice, at a n y r a t e so far as can be j u d g e d by its official recognition, A l t h o u g h the influence of t h e d o c t o r was recognised as beneficial to t h e community, as well as to t h e individual, in H o m e r i c t i m e s and in the early h i s t o r y of E g y p t , such influence sank to n o t h i n g in t h e Middle Ages a n d i m p r o v e d but slightly with the revival of learning which a c c o m p a n i e d t h e R e n a i s s a n c e . It was not, in this country, utatil the 'seventies t h a t public health and p r e v e n t i v e medicine received general public recognition and m a d e a n y effective start. I t is true t h a t the T o w n s h n p r o v e m e n t Clauses Act of 1847 gave power, with m a n y restrictions, to a p p o i n t a salaried "officer of h e a l t h . " T h i s w a s followed b y t h e Public H e a l t h Act of 1848, which was only an " adoptive" Act, and various m i n o r acts, including the N u i s a n c e s R e m o v a l Act, 186o. Dr. Duncan, of Liverpool, was the first medical officer of health, and was a p p o i n t e d under a L o c a l Act in 1847. I t was not until the Public H e a l t h Act of 1872 w a s passed, t h a t the d u t y of a p p o i n t i n g medical officers of health was i m p o s e d upon t h e local authorities in all p a r t s of E n g l a n d and W a l e s outside the metropolis. T h e Act of 1872 divided the whole of E n g l a n d a n d W a l e s , exclusive of the m e t r o polis,into " U r b a n S a n i t a r y Districts and R u r a l S a n i t a r y Districts," as t h e y are now known. All these Acts, and several others, w e r e consolidated in the Public H e a l t h Act of 1875, u n d e r which m o s t of the public health w o r k of the present d a y is still done, t h o u g h there have been several a m e n d i n g Acts, and m a n y " a d o p t i v e " Acts since t h a t time. I t is of s o m e interest, therefore, to the m e m b e r s of the public health service, as well * Presidential Address delivered to the Midland Branch of the Society of Medical Officers of Health, October 5th, I9Ix.