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Prevention of mental defect
PUBLIC H E A L T H , October, 1951 d e v e l o p m e n t o f p o s i t i v e h e a l t h will b e s l o w . O n e m u s t b e p r e p a r e d to a i m f o r b e n e f i t s five o r e v e n t e n g e n e r a t i o n s a h e a d . G e n e t i c p r o g r e s s will n e v e r be c o m p l e t e u n l e s s w e learn to control mutations. B u t s o m e a t t e m p t at artificial s e l e c t i o n is e s s e n t i a l s i n c e e n v i r o n m e n t a l i m p r o v e m e n t b y itself c a n i n m o s t i n s t a n c e s h a v e n o l a s t i n g effect, O n l y by a combination of environmental improvement and genetic improvement can the health standards of the population be permanently and progressively raised.
CORRESPONDENCE VACCINATION POLICY To the Editor of PUBLIC t~[EALTH S I R , - - I have read with interest t h e s t a t e m e n t of Vaccination Policy issued by t h e Council of the Society of Medical Officers of t t e a l t h a n d p u b l i s h e d in t h e A u g u s t issue of PUBLIC HEALTH. I v e n t u r e to s u b m i t a few c o m m e n t s . T h e s t a t e m e n t begins at once on a very confident n o t e : " T h e Society of Medical Officers of H e a l t h reaffirms its c o m p l e t e confidence in vaccination as a m e a n s of protection of the individual a n d the c o m m u n i t y against smallpox, if carried o u t properly a n d at appropriate intervals." N o t h i n g could be m o r e definite t h a n t h a t - - s h o r t , simple a n d to t h e point, a n d w i t h o u t a n y qualification. M a y I s u g g e s t t h a t it is a little too r e a s s u r i n g ? T h e appropriate intervals r e c o m m e n d e d are only twice in a lifetime, in t h e first six m o n t h s of infancy a n d again d u r i n g school age (cf. British troops abroad have to be revaccinated every two years). N o t h i n g is said a b o u t a n y s u p p l e m e n t a r y or alternative m e a s u r e s w h i c h s h o u l d also be carried out. N o d o u b t t h e writers of t h e s t a t e m e n t a s s u m e that these will be carried out, b u t at least t h e y m i g h t have b e e n m e n t i o n e d , for w i t h o u t their help, h a v e we a n y assurance t h a t vaccination alone w o u l d suffice ? T h e evidenee is rather t h e o t h e r way. I n t h e W o r l d H e a l t h O r g a n i s a t i o n ' s Epidemiological and Vital Statistics Report for February-March., 1951, Dr. Pascua, Director of the Division of H e a l t h Statistics of W . H . O . , has a very valuable m o n o g r a p h entitled " E v o l u t i o n of Mortality in E u r o p e d u r i n g t h e T w e n t i e t h C e n t u r y , " in w h i c h h e p u b l i s h e s a table s h o w i n g t h e total smallpox deaths in eight E u r o p e a n countries d u r i n g each of t h e years 1901-49. F r o m this table it appears that t h e countries with t h e lowest smallpox mortality were E n g l a n d a n d W a l e s a n d G e r m a n y . W e u s e d to be taught, d u r i n g t h e early years of this century, that G e r m a n y was t h e o u t s t a n d i n g e x a m p l e of w h a t vaccination could do, b u t I see that in t h e five years 1917-21 G e r m a n y h a d n o fewer t h a n 1,653 deaths. N o figures are given for G e r m a n y later t h a n 1939, b u t if we take t h e 44 years, 1906-49, a n d ignore t h e last nine years for G e r m a n y , I see t h a t she h a d 2,158 deaths c o m p a r e d with only 421 for E n g l a n d a n d Wales. If we reckon h e r p o p u l a t i o n as a p p r o x i m a t e l y twice t h a t of this c o u n t r y it m e a n s that she h a s h a d m o r e t h a n twice as m a n y deaths f r o m s m a l l p o x in p r o p o r t i o n to population, a n d this d u r i n g a period w h e n vaccination h a s b e e n notoriously neglected in this country. A p a r t f r o m G e r m a n y there is no c o u n t r y w h i c h c a n claim to have succeeded in effectively controlling smallpox by vaccination. I m a y be told t h a t in n o c o u n t r y h a s vaccination b e e n satisfactorily carried out, " properly a n d at appropriate intervals." T h i s m a y be true a n d if it h a s n o t b e e n possible in G e r m a n y it is n o t likely to be possible in this country. B u t is it n o t r a t h e r playing w i t h w o r d s to assert that one h a s complete confidence in s o m e t h i n g if properly carried out, w h e n one knows it n e v e r c a n be properly carried out ? Moreover, d u r i n g the last 40 years alternative m e a s u r e s s u c h as hospital isolation a n d t h e control of contacts have b e e n increasingly carried o u t a n d d u r i n g that t i m e smallpox d e a t h s have steadily declined. D u r i n g t h e whole period, 1901-49, t h e r e have have b e e n in this country, as stated above, 421 deaths, b u t d u r i n g t h e last 19 years, 1931-49, t h e r e h a v e b e e n only 52 deaths. It m a y be said that this is only a s h o r t period a n d that s m a l l p o x m a y return, b u t if we look at t h e o t h e r E u r o p e a n countries we n o t e a similar decline. E v e n in S p a i n a n d Italy, w h i c h suffered very severely d u r i n g t h e first q u a r t e r of this century, a n equally dramatic decline h a s occurred. Indeed, it h a s b e e n m u c h m o r e marked. It certainly looks therefore as if smallpox was t e n d i n g to leave Europe, irrespective of vaccination. T h e r e h a s b e e n a similar decline in t h e E u r o p e a n c o u n t r i e s in t h e case of t y p h o i d a n d p a r a t y p h o i d fevers, scarlet fever, w h o o p i n g c o u g h a n d measles. O n e f u r t h e r c o m m e n t : U n d e r (iv) t h e s t a t e m e n t says : " T h a t in the presence of s m a l l p o x in an area, reliance s h o u l d be placed on selective vaccination o f contacts (the " e x p a n d i n g ring " system) a n d n o t o n m a s s vaccination." I q u i t e agree with this
13 b u t it goes o n to say : " T h e Medical Officer of H e a l t h should, however, bear in m i n d that as soon as smallpox is notified in his area, a d e m a n d for m a s s vaccination m a y arise f r o m the public, a n d h e s h o u l d therefore p l a n at once the organisation of s u c h a m e a s u r e . " T h i s p u t s a Medical Officer of Health in a very difficult position. H e is asked to prepare a m e a s u r e in w h i c h he m a y n o t believe, a n d w h i c h is not r e c o m m e n d e d by the Society of M . O . H . , merely because a d e m a n d for it m a y arise f r o m the public. Surely it seems desirable that t h e M i n i s t r y of Health s h o u l d issue in advance a very definite s t a t e m e n t that m a s s vaccination is n o t in ordinary c i r c u m s t a n c e s desirable. As regards Dr. R u t h e r f o r d C r a m b ' s letter ( P v m ; c Hv.u.vu, September, 1951), he w r i t e s : "1 viewed t h e m o u n t i n g figures of vaccination with satisfaction a n d consider this preventive m e a s u r e played an i m p o r t a n t role in l i m i t i n g the spread. W h i l e there were many. instances of its efficacy I q u m c one. T h i s was an u n v a c c i n a t e d widow with an u n v a c c i n a t e d son of 12~: she was a domestic in Bevendean Hospital, who lived n u t and contracted smallpox (Case 13). When the ambulance a t t e n d a n t s arrived to remove her the boy c h m g to his mother, e m b r a c i n g a n d kissing her. Her rash was then well Grit. As there' were no relatives he was vaccinglted ilnllle diately, taken to the hospital a n d kept there in an isolated side-room. He did not contract s m a l l p o x : his m o t h e r died." I a m at a loss to t m d e r s t a n d why Dr. C r a m b should quote this case, as it was clearly not one of " mass vaccination." I should t ertainly have vaccin'ated s u c h a ease myself, as it was a known a n d close contact. Y o u r s faithfully, T h e Gilroes, C. KILIACK MILl.ram. Leicester. September l lth, 1951. PREVENTION OF MENTAL DEFECT
To the Editor of Pure.It HeaLwrI S m , - - W i t h reference to Dr. J o n e s ' s interesting article, " T h e Social Implications of M e n t a l Deficiency, ' ' * I w o n d e r w h y t h e r e is so little m e n t i o n in t h e literature h o w we m a y reduce the incidence of mental defect. I a m sure that y o u r readers will have m a n y s u g g e s t i o n s to make. I have in m i n d s o m e rules, e.g., ever3" m o t h e r to h a v e a W a s s e r m a n n a n d / o r K a h n test a n d a test for R h e s u s factor in every p r e g n a n c y ; better control of infectious disease in early pregnancy, e.g., rubella a n d respiratory disorders. Are there a n y other suggestions ? Y o u r s faithfully, September 12th, 1951. ENQUIRER. * PUBLIC HEALTH (August, 1951), 64, 206. R . M . B . F . CHmSTMAS GIFTS FUND APPEAl. To the Editor of PUBLIC HEALTH S n ~ , - - I appeal to m e m b e r s of the Medical Profession, w h e t h e r s u b s c r i b e r s or not, to send d o n a t i o n s to t h e C h r i s t m a s Gifts F u n d for Beneficiaries of t h e Royal Medical Benevolent F u n d . T h e C o m m i t t e e generally try to s e n d a p r e s e n t of £ 5 to each Beneficiary. I, therefore, h o p e that there will be a g e n e r o u s r e s p o n s e to this Appeal. C h r i s t m a s gifts have a very deep a n d special significance for t h e y m a k e t h e Beneficiaries realise that they are b e i n g r e m e m b e r e d b y their m o r e f o r t u n a t e colleagues. I n the p r e s e n t difficult t i m e s C h r i s t m a s gifts are m o r e u r g e n t l y n e e d e d t h a n ever before. C o n t r i b u t i o n s s h o u l d be sent to t h e Secretary of t h e Royal M e d i c a l B e n e v o l e n t F u n d , 1, Balliol H o u s e , M a n o r Fields, P u t n e y , L o n d o n , S.W. 15, a n d m a r k e d " C h r i s t m a s G i f t s . " Y o u r s very truly, 1, Balliol H o u s e , WEBB-JOIINSON, M a n o r Fields, President, Putney, Royal Medical Benerolent Fund. L o n d o n , S.W.15. September Ist, 1951.
INSTALLATION
OF
PRESIDENT,
1951-52
Dr. W. G. Clark, medical officer of health, City of E d i n b u r g h , will be installed as President of the Society of Medical Officers of H e a l t h for the session 1951-52 By the retiring President (1)1". J. M. Gibson) at an Ordinary Meeting to be held at Tavistock H o u s e London, W.C.1, on T h u r s d a y , October 18th, 1951, at 5.30 p.m. Dr. Clark will deliver his "Presidential Address after his installation.
CORRESPONDENCE VACCINATION POLICY To the Editor of PUBLIC t~[EALTH S I R , - - I have read with interest t h e s t a t e m e n t of Vaccination Policy issued by t h e Council of the Society of Medical Officers of t t e a l t h a n d p u b l i s h e d in t h e A u g u s t issue of PUBLIC HEALTH. I v e n t u r e to s u b m i t a few c o m m e n t s . T h e s t a t e m e n t begins at once on a very confident n o t e : " T h e Society of Medical Officers of H e a l t h reaffirms its c o m p l e t e confidence in vaccination as a m e a n s of protection of the individual a n d the c o m m u n i t y against smallpox, if carried o u t properly a n d at appropriate intervals." N o t h i n g could be m o r e definite t h a n t h a t - - s h o r t , simple a n d to t h e point, a n d w i t h o u t a n y qualification. M a y I s u g g e s t t h a t it is a little too r e a s s u r i n g ? T h e appropriate intervals r e c o m m e n d e d are only twice in a lifetime, in t h e first six m o n t h s of infancy a n d again d u r i n g school age (cf. British troops abroad have to be revaccinated every two years). N o t h i n g is said a b o u t a n y s u p p l e m e n t a r y or alternative m e a s u r e s w h i c h s h o u l d also be carried out. N o d o u b t t h e writers of t h e s t a t e m e n t a s s u m e that these will be carried out, b u t at least t h e y m i g h t have b e e n m e n t i o n e d , for w i t h o u t their help, h a v e we a n y assurance t h a t vaccination alone w o u l d suffice ? T h e evidenee is rather t h e o t h e r way. I n t h e W o r l d H e a l t h O r g a n i s a t i o n ' s Epidemiological and Vital Statistics Report for February-March., 1951, Dr. Pascua, Director of the Division of H e a l t h Statistics of W . H . O . , has a very valuable m o n o g r a p h entitled " E v o l u t i o n of Mortality in E u r o p e d u r i n g t h e T w e n t i e t h C e n t u r y , " in w h i c h h e p u b l i s h e s a table s h o w i n g t h e total smallpox deaths in eight E u r o p e a n countries d u r i n g each of t h e years 1901-49. F r o m this table it appears that t h e countries with t h e lowest smallpox mortality were E n g l a n d a n d W a l e s a n d G e r m a n y . W e u s e d to be taught, d u r i n g t h e early years of this century, that G e r m a n y was t h e o u t s t a n d i n g e x a m p l e of w h a t vaccination could do, b u t I see that in t h e five years 1917-21 G e r m a n y h a d n o fewer t h a n 1,653 deaths. N o figures are given for G e r m a n y later t h a n 1939, b u t if we take t h e 44 years, 1906-49, a n d ignore t h e last nine years for G e r m a n y , I see t h a t she h a d 2,158 deaths c o m p a r e d with only 421 for E n g l a n d a n d Wales. If we reckon h e r p o p u l a t i o n as a p p r o x i m a t e l y twice t h a t of this c o u n t r y it m e a n s that she h a s h a d m o r e t h a n twice as m a n y deaths f r o m s m a l l p o x in p r o p o r t i o n to population, a n d this d u r i n g a period w h e n vaccination h a s b e e n notoriously neglected in this country. A p a r t f r o m G e r m a n y there is no c o u n t r y w h i c h c a n claim to have succeeded in effectively controlling smallpox by vaccination. I m a y be told t h a t in n o c o u n t r y h a s vaccination b e e n satisfactorily carried out, " properly a n d at appropriate intervals." T h i s m a y be true a n d if it h a s n o t b e e n possible in G e r m a n y it is n o t likely to be possible in this country. B u t is it n o t r a t h e r playing w i t h w o r d s to assert that one h a s complete confidence in s o m e t h i n g if properly carried out, w h e n one knows it n e v e r c a n be properly carried out ? Moreover, d u r i n g the last 40 years alternative m e a s u r e s s u c h as hospital isolation a n d t h e control of contacts have b e e n increasingly carried o u t a n d d u r i n g that t i m e smallpox d e a t h s have steadily declined. D u r i n g t h e whole period, 1901-49, t h e r e have have b e e n in this country, as stated above, 421 deaths, b u t d u r i n g t h e last 19 years, 1931-49, t h e r e h a v e b e e n only 52 deaths. It m a y be said that this is only a s h o r t period a n d that s m a l l p o x m a y return, b u t if we look at t h e o t h e r E u r o p e a n countries we n o t e a similar decline. E v e n in S p a i n a n d Italy, w h i c h suffered very severely d u r i n g t h e first q u a r t e r of this century, a n equally dramatic decline h a s occurred. Indeed, it h a s b e e n m u c h m o r e marked. It certainly looks therefore as if smallpox was t e n d i n g to leave Europe, irrespective of vaccination. T h e r e h a s b e e n a similar decline in t h e E u r o p e a n c o u n t r i e s in t h e case of t y p h o i d a n d p a r a t y p h o i d fevers, scarlet fever, w h o o p i n g c o u g h a n d measles. O n e f u r t h e r c o m m e n t : U n d e r (iv) t h e s t a t e m e n t says : " T h a t in the presence of s m a l l p o x in an area, reliance s h o u l d be placed on selective vaccination o f contacts (the " e x p a n d i n g ring " system) a n d n o t o n m a s s vaccination." I q u i t e agree with this
13 b u t it goes o n to say : " T h e Medical Officer of H e a l t h should, however, bear in m i n d that as soon as smallpox is notified in his area, a d e m a n d for m a s s vaccination m a y arise f r o m the public, a n d h e s h o u l d therefore p l a n at once the organisation of s u c h a m e a s u r e . " T h i s p u t s a Medical Officer of Health in a very difficult position. H e is asked to prepare a m e a s u r e in w h i c h he m a y n o t believe, a n d w h i c h is not r e c o m m e n d e d by the Society of M . O . H . , merely because a d e m a n d for it m a y arise f r o m the public. Surely it seems desirable that t h e M i n i s t r y of Health s h o u l d issue in advance a very definite s t a t e m e n t that m a s s vaccination is n o t in ordinary c i r c u m s t a n c e s desirable. As regards Dr. R u t h e r f o r d C r a m b ' s letter ( P v m ; c Hv.u.vu, September, 1951), he w r i t e s : "1 viewed t h e m o u n t i n g figures of vaccination with satisfaction a n d consider this preventive m e a s u r e played an i m p o r t a n t role in l i m i t i n g the spread. W h i l e there were many. instances of its efficacy I q u m c one. T h i s was an u n v a c c i n a t e d widow with an u n v a c c i n a t e d son of 12~: she was a domestic in Bevendean Hospital, who lived n u t and contracted smallpox (Case 13). When the ambulance a t t e n d a n t s arrived to remove her the boy c h m g to his mother, e m b r a c i n g a n d kissing her. Her rash was then well Grit. As there' were no relatives he was vaccinglted ilnllle diately, taken to the hospital a n d kept there in an isolated side-room. He did not contract s m a l l p o x : his m o t h e r died." I a m at a loss to t m d e r s t a n d why Dr. C r a m b should quote this case, as it was clearly not one of " mass vaccination." I should t ertainly have vaccin'ated s u c h a ease myself, as it was a known a n d close contact. Y o u r s faithfully, T h e Gilroes, C. KILIACK MILl.ram. Leicester. September l lth, 1951. PREVENTION OF MENTAL DEFECT
To the Editor of Pure.It HeaLwrI S m , - - W i t h reference to Dr. J o n e s ' s interesting article, " T h e Social Implications of M e n t a l Deficiency, ' ' * I w o n d e r w h y t h e r e is so little m e n t i o n in t h e literature h o w we m a y reduce the incidence of mental defect. I a m sure that y o u r readers will have m a n y s u g g e s t i o n s to make. I have in m i n d s o m e rules, e.g., ever3" m o t h e r to h a v e a W a s s e r m a n n a n d / o r K a h n test a n d a test for R h e s u s factor in every p r e g n a n c y ; better control of infectious disease in early pregnancy, e.g., rubella a n d respiratory disorders. Are there a n y other suggestions ? Y o u r s faithfully, September 12th, 1951. ENQUIRER. * PUBLIC HEALTH (August, 1951), 64, 206. R . M . B . F . CHmSTMAS GIFTS FUND APPEAl. To the Editor of PUBLIC HEALTH S n ~ , - - I appeal to m e m b e r s of the Medical Profession, w h e t h e r s u b s c r i b e r s or not, to send d o n a t i o n s to t h e C h r i s t m a s Gifts F u n d for Beneficiaries of t h e Royal Medical Benevolent F u n d . T h e C o m m i t t e e generally try to s e n d a p r e s e n t of £ 5 to each Beneficiary. I, therefore, h o p e that there will be a g e n e r o u s r e s p o n s e to this Appeal. C h r i s t m a s gifts have a very deep a n d special significance for t h e y m a k e t h e Beneficiaries realise that they are b e i n g r e m e m b e r e d b y their m o r e f o r t u n a t e colleagues. I n the p r e s e n t difficult t i m e s C h r i s t m a s gifts are m o r e u r g e n t l y n e e d e d t h a n ever before. C o n t r i b u t i o n s s h o u l d be sent to t h e Secretary of t h e Royal M e d i c a l B e n e v o l e n t F u n d , 1, Balliol H o u s e , M a n o r Fields, P u t n e y , L o n d o n , S.W. 15, a n d m a r k e d " C h r i s t m a s G i f t s . " Y o u r s very truly, 1, Balliol H o u s e , WEBB-JOIINSON, M a n o r Fields, President, Putney, Royal Medical Benerolent Fund. L o n d o n , S.W.15. September Ist, 1951.
INSTALLATION
OF
PRESIDENT,
1951-52
Dr. W. G. Clark, medical officer of health, City of E d i n b u r g h , will be installed as President of the Society of Medical Officers of H e a l t h for the session 1951-52 By the retiring President (1)1". J. M. Gibson) at an Ordinary Meeting to be held at Tavistock H o u s e London, W.C.1, on T h u r s d a y , October 18th, 1951, at 5.30 p.m. Dr. Clark will deliver his "Presidential Address after his installation.