Prevention—Medical and economic

16

P U B L I C H E A L T H , November, 1952

reproduce in this journal) by Dr. Ffrangcon i Rot~erts. Thereafter, the m e m b e r s adjourned to the L o n d o n School of H y g i e n e and T r o p i c a l Medicine, where a 'distinguished former m e m b e r , Prof. J. M. Mackintosh, gave a fascinating account, illustrated by photographs and exhibits, of the founder m e m b e r s and the early doings of the Association. T h e final event of a m e m o r a b l e day was a jubilee dinner, also at the L o n d o n School, w h e n the toast of the Association was proposed by Mr. G. L. C. Elliston, who described C o u n t y M . O . s as the landed gentry of the Public H e a l t h Service ; Dr. T o w n s e n d wittily replied. Dr. H. K e n n e t h Cowan then gave a hearty welcome to the guests, for w h o m Mr. W. L. Dacey, Secretary of the C.C.A., cordially responded.

PREVENTION--MEDICAL

AND ECONOMIC *

By ANDREW TOPPING,T.D., M.A., M.D., F.R.C.P., F.R.S.E., D.P.H., Dean, The London ,School of Hygiene and Tropical Medicine I am proud, although somewhat chastened, at the thought that I am the 72nd President of this venerable and famous Society which goes back to 1 8 5 6 ; in four years it will celebrate its centenary. In that period there have been m a n y illustrous names on the roll of Presidents, Sir J o h n Simon, formerly Medical Officer of Health for the City of London, and at the time of his presidency, 1856-61, Medical Officer to the Privy Council, being the first. T h e r e have been m a n y others whose names a r e very well known, and others who are not so familiar and have no particular claim to fame apart from the fact that they have all been selected by their fellowmembers, which in itself goes to prove that t h e y m u s t have had some outstanding quality. I have enquired as to any research that is being carried out to ensure that the Presidential Addresses of the past are to remain available for future Presidents and others, and I am r e m i n d e d that the records of the first 50 years have been written up in the Jubilee N u m b e r of PUBLIC HEALTH published in 1906, and that Dr. Walton, of N e w c a s t l e - u p o n - T y n e , is preparing a follow-up history of the subsequent years to the present day for the Centenary Celebrations. Dr. G. F. Buchan was President in t925-26 and I am happy that he is able to be with us to-day. O f the subsequent 25 Presidents, 17 are still alive, which would go to suggest that as a class they are fairly long-lived, and that probably applies also to Medical OfFicers of Health too. In view of some remarks I hope to make later on, this latter fact m a y not be altogether a good thing, In the first 60 years of our Society the Presidents were engaged in the practice of old-time preventive medicine and dealt with the particular needs of their t i m e - - i m p r o v e m e n t of water supplies, sanitation and the control of infectious diseases. Thereafter, in the years just before and just after the first W o r l d War, there were very great changes, brought about by the d e v e l o p m e n t of Local Authorities and personal health services, provisions of hospitals and dispensaries, ante-natal services and so on, and there accrued a n u m b e r of m e m b e r s r,r the Society w h o were not Medical Officers of Health. F r o m this growing section there arose considerable justifiable criticism w h e n I joined the Society some 30 years ago. It is very important, in m y opinion, that m o r e of the j u n i o r medical officers should be able to attend meetings of the Society and I think that medical officers of health should persuade their local authorities that it would be of service to the work of their areas if the j u n i o r staff were allowed to do so, that is to say, that they should be given the necessary time off from their duties and encouraged to take a m o r e active part in the work of the Society. T h e r e are, I understand, Presidential Address to the Society of Medical Officers of Health, London, September 17th, 1952.

a n u m b e r of those attending the present School Medical Officers' Course who are not members of the Society, who have expressed complete approval with the arrangements made, and I would like to take this opportunity to say that there is to be a change in the name of the Society which will go a long way towards enabling t h e m to become members, and meet some of the objections that have been made to the present constitution. T h e new title for which the Council will seek the m e m b e r s ' approval is " T h e Society of Preventive M e d i c i n e . " T h e r e has been only one Departmental Medical Officer who has been President - - t h e late Dr. Ernest Ward, a w e l l - r e m e m b e r e d tuberculosis officer. Dr. E. H. T . N a s h was President as an M . O . H . but most of his work and interests were in Child Welfare. T h e Presidential Addresses of most of m y predecessors have dealt, quite understandably, with the changes in public health and what was going to happen to it in the future. In thinking the m a t t e r over, I find that I have some attributes in which I appear to be unique : the first, that I appear to be the first graduate of A b e r d e e n University ever to be called to this office, and this surprises me w h e n I think of the Aberdonians who have been famous in the public health field ; I have heard it said that it is probably because the post is entirely honorary and carries no salary whatsoever. Secondly, I a m the first President who has had, as a distinct p a r t of his job, a close association with tropical m e d i c i n e ; and lastly, I am the third President to have held an academic post in the public health field, the other two having been H. R. K e n w o o d and R. M. F'. Picken. The Finance of Health As an Aberdonian, it is appropriate that I should first deal with the subject of finance. F o r generations we have been preaching that prevention of disease, largely by r e m o v i n g the conditions which conduce to it, is not only the logical approach but is also very m u c h less expensive than curative efforts. I have talked on this subject on m a n y occasions and from all sorts of pulpits but not yet, as was suggested in a recent editorial in The Medical OoOicer, from a soap box at Marble Arch. W i t h each sHcceeding year the costs of curative medicine have been soaring and there seems to be no limit. Patients suffering f r o m illnesses which are avoidable, and could be cured quite easily, are encouraged to go to the hospital and to the specialist. Local authorities say that prevention is the thing we have to concentrate on, b u t no one is doing it. W e all r e m e m b e r perfectly well H u g h Paul's illustration of the cost of curing the blue baby which will never be a normal child and to h o w m u c h better use that m o n e y could be put in saving the life of innumerable children by preventive measures, by improvements in environment, working conditions, etc. T h e same applies to tuberc u l o s i s : m u c h of the m o n e y being spent on sanatoria could be used so m u c h m o r e effectively in educating the people on the prevention of tuberculosis, by telling t h e m what the~; are doing which causes m a n y m o r e cases than ever are due to K o c h ' s bacillus. T h e n there is the expenditure on 'prematurity. Speaking without expert knowledge but f r o m m y own exverience m a n y years ago, I a m convinced that a large proportion of cases of prematurity is due to inadequate ante-natal care and unwillingness to follow instructions. T h e m o d e m prematurity unit is most expensive. T h e right thing to do is to educate the public and so stop the large n u m b e r of these cases that are occurring. Bradford Hill and his team of workers issued a very important report on an investigation on the possible relation of smoking to the large increase in lung cancer. T h e publicity given to it was negligible and it is appalling to see the n u m b e r of adolescents in cinemas and other public places smoking continuously for want of a concentrated effort to educate t h e m in the possible result ; no, it is easier to order another deep therapy unit at a colossal cost I W e do not get m u c h help in this matter either f r o m the general practitioner or the consultant branch of the

PUBLIC HEALTH,

November, 1952

profession. T h e r e may, however, b e an answer to t h e whole q u e s t i o n of cost a n d t h a t is in the p r e s e n t financial position of the c o u n t r y : we c a n n o t afford t h e s e h i g h costs a n d t h e r e m a y b e a swing towards p r e v e n t i o n as b e i n g the c h e a p e r expedient, b u t it is a pity t h a t this m a y be forced o n us b y t h e financial situation r a t h e r t h a n b y conviction.

Training in Preventive Medicine M o s t medical schools, with some of the m o s t r e n o w n e d p r o v i d i n g glaring exceptions, have i m p r o v e d t h e quality a n d the q u a n t i t y of t h e i r u n d e r g r a d u a t e teaching, b u t t h e r e is still a l o n g way to go. H e r e again t h e r e is often little m o r e t h a n lip service paid b y the clinical teachers, some going so far as to say t h a t t h e r e is little n e e d for extension a n d t h a t t h e subject n e e d no longer b e i n c l u d e d in the qualifying examination. T h e d o c t o r w h o is n o t fully cognisant of t h e p a r t played by avoidable factors in lessening health, m e n t a l a n d bodily, is n o t c o m p e t e n t to pull his full w e i g h t as a family doctor or as a specialist. T h e g l a m o u r of clinical w o r k w i t h i t s great rewards in p e r s o n a l satisfaction a n d g r a t i t u d e of the p a t i e n t m u s t always have a great appeal. Success in p r e v e n t i v e work m a y a n d usually does confer m u c h greater benefit to the c o m m u n i t y a n d the individuals w h o c o m p o s e it b u t it is rarely spectacular a n d has little news value~ T h e teacher of P r e v e n t i v e Medicine, be he a f u l l - t i m e professor or t h e M . O . H . of the U n i v e r s i t y town, will n e v e r be able to exercise full influence on t h e s t u d e n t m i n d unless he has t h e c o - o p e r a t i o n of t h e clinicians, all of w h o s e t e a c h i n g s h o u l d stress t h e social factors w h i c h have c o n d u c e d to or caused t h e disease a n d w h i c h if n o t recognised a n d r e m o v e d or m i n i m i s e d will m a k e t h e i r curative effects palliative a n d t e m p o r a r y . T h e t e a c h i n g of p r e v e n t i v e m e d i c i n e s h o u l d b e d o n e in t h e w a r d or, as in E d i n b u r g h , w h e r e they have e s t a b l i s h e d a w o n d e r f u l system a n d t e a c h it in t h e h o m e s of t h e patients, t h u s m a k i n g t h e clinical a n d social picture one. U n t i l we can get t h e teachers really interested t h e s t u d e n t will c o n t i n u e to look u p o n P r e v e n t i v e M e d i c i n e as a s u b s i d i a r y subject to the big three, Habits, e n v i r o n m e n t , occupation, p o p u l a t i o n t r e n d s are m o s t i m p o r t a n t to t h e m e d i c a l s t u d e n t if he is to serve m a n k i n d a n d help t h e p u b l i c to u n d e r s t a n d how t h e y can p r e v e n t ill-health.

Tropical' Medicine and Malthus A p a r t f r o m ~ome experience in m o s t E u r o p e a n countries, some of t h e m b y o u r s t a n d a r d s backward, I have h a d several o p p o r t u n i t i e s of visiting o u r W e s t A f r i c a n Colonies. T h e r e , only in greater degree, the same p r o b l e m s face us as in this c o u n t r y : h o u s i n g is disgraceful, avoidable illn e s s - i n s e c t a n d w a t e r - b o r n e - - i s r a m p a n t , t h e cloud of i g n o r a n c e a b o u t disease is even thicker, t h e status of the w i t c h d o c t o r w h o k n o w s " all the answers " is h i g h e r t h a n t h a t of the m a n w h o s e only claim is t h a t his efforts will p r e v e n t disease. T h e authorities have to provide curative facilities--dispensaries, clinics a n d hospitals, to m e e t p u b l i c d e m a n d . Obviously, s u c h services are necessary b u t t h e y s h o u l d b e looked u p o n as only a t o k e n to gain the confidence of the people a n d to p r e p a r e t h e m for a r a p i d e x t e n s i o n of the p r e v e n t i v e services w h i c h w o u l d cut off 90 p e r cent. of the disease at t h e source. I t appears so obvious t h a t full priority s h o u l d b e g i v e n to the i m p r o v e m e n t of n u t r i tion, to t h e p r o v i s i o n of d e c e n t w a t e r supply, to t h e clearance of the b u s h areas i n w h i c h t h e tsetse breed, to drainage of the m o s q u i t o b r e e d i n g g r o u n d s ~nd to e d u c a t i o n of t h e people in t h e real causes of t h e m a j o r i t y of t h e i r e n d e m i c d i s e a s e s : even m o r e i m p o r t a n t t h a n any of these is i m p r o v e m e n t in agricultural m e t h o d s a n d t h e i r general economy. N a t u r e is a v e r y wise old m o t h e r a n d h e r ecological control has t h r o u g h t h e ages c o n t r i v e d to strike a balance b e t w e e n food a n d p o p u l a t i o n . T h a t h e r m e t h o d s are cruel c a n n o t be denied, b u t we m u s t t h i n k v e r y carefully

17 before we u p s e t her balance ; the last result m a y well be worse t h a n t h e first if we, by o u r efforts, interfere w i t h t h e n a t u r a l laws of selection a n d survival w i t h o u t t a k i n g p r i o r steps to e n s u r e at least equal c h a n g e s in the level of food supplies. T h e r e are two schools of t h o u g h t : one holds t h a t b y r e d u c i n g i n f a n t m o r t a l i t y a n d b y e r a d i c a t i n g the e n d e m i c diseases the resulting larger a n d h e a l t h i e r p o p u l a t i o n will b e able to p r o d u c e m o r e food ; the o t h e r claims t h a t u n t i l b e t t e r m e t h o d s of agriculture, w i t h g r e a t e n r i c h m e n t of t h e soil a n d b e t t e r seed, are a d o p t e d , i m p r o v e m e n t in yield is impossible in m o s t of the areas in q u e s t i o n and t h e r e f o r e we s h o u l d p o s t p o n e m a j o r h e a l t h m e a s u r e s w i t h t h e i r inevitable p o p u l a t i o n increase u n t i l t h e various countries have s h o w n t h a t the extra m o u t h s can, in fact, b e fed. I realise t h a t I a m arguing in a circle a n d that, h o w e v e r justifiable b y cold logic t h e policy of w i t h h o l d i n g t h e benefits of m o d e r n p r e v e n t i v e k n o w l e d g e m a y be, we m u s t c o n t i n u e and, indeed, accelerate o u r efforts to raise the h e a l t h s t a n d a r d s in those b a c k w a r d countries. But may I m a k e a s t r o n g plea t h a t i m p r o v e m e n t in general e c o n o m y , in e d u c a t i o n a n d in agriculture m u s t at least a c c o m p a n y , if it c a n n o t precede, these measures.

Quantity and Quality I n o u r o w n c o u n t r y the greatest p r o b l e m facing us is the steadily g r o w i n g p r o p o r t i o n of old people to young. T h e spectacular r e d u c t i o n in the infantile m o r t a l i t y rate c o u p l e d w i t h a greatly increased expectation of life, due partly to t h e f o r m e r a n d partly to t h e a c h i e v e m e n t s of t h e scientists w i t h t h e i r e v e r - g r o w i n g n u m b e r of lifesaving a n d p r o l o n g i n g drugs, has already m a d e a significant c h a n g e in age-group d i s t r i b u t i o n . W h e n , as is inevitable, t h e y p r o d u c e s o m e t h i n g w h i c h will even f u r t h e r delay t h e o n s e t of degenerative c o n d i t i o n s of t h e cardiovascular s y s t e m a n d w h e n , as is also certain, the exact exciting cause of t h e various m a l i g n a n t diseases is p i n p o i n t e d , the tag t h a t in 20 years' t i m e we will have too m a n y people in b a t h - c h a i r s and too few to p u s h t h e m will be a gross u n d e r - s t a t e m e n t . Failing v o l u n t a r y or c o m p u l s o r y e u t h a n a s i a or a great increase in the b i r t h - r a t e , this d i s p r o p o r t i o n will increase b y geometrical progression. I do n o t expect t h a t t h e b i r t h - r a t e will i n fact show any m a t e r i a l c h a n g e ; t h e distressing feature is t h a t far too large a p e r c e n t a g e of the b i r t h s are o c c u r r i n g in t h e lower strata of the p o p u l a t i o n a n d usually to t h e m o s t careless a n d i r r e s p o n s i b l e : the t h i n k i n g section of all grades, especially in t h e m i d d l e c l a s s e s - - b y far t h e m o s t i m p o r t a n t g r o u p - - a r e p r o d u c i n g far too few c h i l d r e n a n d this, I s u b m i t , largely irrespective of t}xeir religious beliefs. B i r t h control is a n u n f o r t u n a t e title w i t h its implication of restraint; family advice, w h i c h has b e e n suggested as an alternative, is colourless a l t h o u g h i t h a s the g e r m of the idea. W e as a b o d y interested in P u b l i c H e a l t h in its widest sense should, I think, do all we can to impress u p o n t h e powers t h a t be a n d t h e t h i n k i n g p a r t of the c o m m u n i t y t h a t m o r e children b o r n to t h e right type of parents are one of ,the c o u n t r y ' s greatest needs.

Dr. J. Greenwood Wilson, Medical Officer of Heahh. Cardiff, has been elected an Honorar'r Fellow of the American Public Health Association. Professor W. M. Frazer, O.B.E., ra.n., D.P.rl., Medical Officer of Health, City of Liverpool, has accepted an invitatio~a from the University of London to give the Newsholme Lectures--three in number~