Reflections on preventive medicine

P U B L I C H E A L T H , January, 1945 DIAGRAM B Twenty-one New Ships

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T h e q u a r t e r s of ships built since 1937 are an i m p r o v e m e n t ; in a few cases t h e y are excellent ; the regulations are n e v e r t h e less b e i n g e n f o r c e d loosely in t h e ease of s o m e o f t h e m . T h e t w o i m p r o v e m e n t s m o s t n e e d e d are (a) an increase in t h e space s t a n d a r d in sleeping q u a r t e r s ; (b) t h e p l a n s of t h e crews' q u a r t e r s of every ship should b e passed b y a medical officer w i t h experience of p o r t health w o r k before c o n s t r u c t i o n is started. I have to thank the Director of Medical Services, Nigeria, for permission to publish this paper.

,j REFERENCES

for all seamen in the 60 ships. The diagram shows that over 57% of the seamen have less than 12 sq. ft. of floor space each ; 15"4% fall into the grossly overcrowded group, who each have only 4, 5 or 6 sq. ft. ; at the other extreme there are about 4% who are fortunate enough to have more than 22 sq. ft. each. In Diagram B the free floor space in the sleeping quarters of the 21 new ships is shown. When compared with the diagram for all ships it can be seen that there is a definite improvement. 41.7% of the men in the new ships have less than 12 sq. ft. each, but only 18% are below the 10-sq.-ft.-per-man level. ~ CERTIFIED TO, ACCOMMODATE ~'

The Merchant Shipping Act requires that the words " Certified to Accommodate . . . Seamen " be cut in a beam on each cabin. This rule has slowly been forgotten. Only 149 cabins (about Onethird) were so labelled. In 47 of these it was quite impossible to agree that the cabin was capable of accommodating the number for which it was certified. In older ships the words are often painted over and obscured. In one-third of the new ships there had been no attempt to follow this rule. This is unfortunate, as the idea is a good one. PREVENTION OF OVERCROWDING

It is to be remembered that any overcrowding which is temporary and due to conditions of war has been excluded from this survey. Why are the crews' sleeping quarters so frequently overcrowded ? Undoubtedly the initial survey is sometimes made in a careless rffanner. The Board of Trade surveyors are not public health officers and may not be particularly interested in the space standard. When a ship is built the owners may fail to allow for a possible increase in the number of the crew, as a result extra bunks are sometimes added to the cabins at a later date (one has seen examples of this). Resurveys of the space in crews' quarters is made only on rare occasions ; so added bunks are seldom detected. Two-thirds of the ships in this series had coloured crews. This was to be expected in a tropical port. This is one reason why the findings were not more satisfactory. In the case of coloured crews any regulations which are only recommendations ai'e usually ignored and other rules are less well enforced. All future rules should apply to coloured seamen to exactly the same extent as to British seamen. Their health is worth protecting if they are to man British ships. If a lower space standard were allowed for coloured seamen there might be a tendency to employ them in increasing numbers and to displace British sailors from employment. Apart from other disadvantages this would be serious for reasons of national security. Port sanitary staff regularly inspect ships for sanitary" nuisances in every large port in the Empire. There is available, therefore, at no increased expense staff to re-inspect ships for structural defects. If port health officers in every large port could enforce the correction of structural defects discovered by their inspectors, then ship designers would soon learn that it was cheaper to construct crews' quarters satisfactorily from the start. Summary Statistics s h o w t h a t seafaring is a n o c c u p a t i o n w i t h a h i g h mortality. T h e British s e a m e n ' s h e a l t h gets less a t t e n t i o n t h a n d o e s t h e health o f his fellow c o u n t r y m a n ashore. T h e laws relating to health c o n d i t i o n s afloat are out o f date. T h e m a i n A c t r e q u i r e s revision. T h e n e w I n s t r u c tions to Surveyors, t h o u g h an i m p r o v e m e n t , n e e d to be m a d e m o r e definite. T h e findings are p r e s e n t e d o f a s u r v e y o f t h e a c c o m m o d a tion p r o v i d e d for 1,857 seamen i n 60 British ships, a n d it is s h o w n t h a t t h e existing regulations are n o t b e i n g e n f o r c e d as t h e y s h o u l d be, especially in ships w i t h coloured crews,

~HOME. (1934). Lancet, 1, 1081. *Registrar-General's Decennial Supplement, England and Wales, 1931. Pt. II. Occupational Mortality. H.M. Stationery Office, 1938. *WooD. (1942). Brit. reed. 3*.. 1, 716. *WILSON. (1936), Lancet, 2. 645: SBROOKE. (1920), Marine Hygiene and Sanitation. p. 30. Bailli~re, Tindall & Cox *HOME. (1922). Merchant Seamen, p. 34. John Murray. 7CADMAN. (1935). Med. Off., 54, 25-26. 8DEARDEN. (1929), "Ann. Rep. M . O . H . Port San. Authority, Port of Manchester. ~PAYNE. (1943). PUBLICHEALTH, 66, 93.

REFLECTIONS

ON PREVENTIVE

MEDICINEe

B y H . R. TIGHE, M.D., F.R.C.S.,I., D.P.H.,

Medical Officer of Health, Swansea C.B. T h e r e is a p o p u l a r c o n c e p t i o n of t h e f u n c t i o n Of t h e general p r a c t i t i o n e r w h i c h , h a v i n g b e e n a d o p t e d by a c e r t a i n section of t h e c o m m u n i t y , seenas to h a v e i n v a d e d m e d i c a l t h o u g h t a n d has b e g u n to a p p e a r in m e d i c a l p l a n n i n g . T h i s is the idea t h a t t h e f u n c t i o n o f t h e d o c t o r is to p r e v e n t disease a n d to i m p r o v e health, t h a t t h e clinical d o c t o r s h o u l d b e p r e v e n t i v e m i n d e d a n d n o t c u r a t i v e - m i n d e d . W e u s e d to b e t o l d t h a t this was t h e t h e o r y of t h e a n c i e n t C h i n e s e , w h o w e r e said t o have p a i d t h e i r d o c t o r s for k e e p i n g away sickness. It w a s n o t to be e x p e c t e d that those w h o failed to see any w e a k n e s s in this p l a n as applied to a n c i e n t C h i n a could see any difficulty in a d a p t i n g it to t h e m o d e r n w o r l d , a l t h o u g h it m a y b e a m a t t e r f o r surprise that so m a n y in t h e p r o f e s s i o n itself were r e a d y to play w i t h t h e idea t h a t t h e g e n e r a l p r a c t i t i o n e r o f the f u t u r e is likely to earn his living b y k e e p i n g p e o p l e welt. T h a t this o p i n i o n is p r e v a l e n t is r e n d e r e d m a n i f e s t n o t only b y s t a t e m e n t s t h a t a p p e a r f r o m t i m e to t i m e in t h e m e d i c a l press, some of w h i c h m a y p o s s i b l y b e o f t h e n a t u r e of lip service, b u t b y t h e p r o n o u n c e m e n t of leaders o f m e d i c a l t h o u g h t in i m p o r t a n t r e p o r t s , A s a n e x a m p l e o f t h e latter, I q u o t e t h e two following e x t r a c t s : - " The Cothmission has adopted for the purpose of its discussion the following broad divisions of the subject of medical service in this country : (a) T o provide a system of medical service directed towards the achievement of positive health, the prevention of disease and the relief of sickness." (Medical

Planning Commission Draft Interim Report.) " Last, but n o t least, personal health tends to be regarded as something to be treated when at fault, but seldom as something to be positively improved and promoted and made full and robust. Much of present custom and habit still centres on the idea that the doctor and the hospital and the clinic are the means of mending ill-health rather than of increasing good health and the sense of well-being." (The White Paper, " A National Health Service," page 8.) I p r o p o s e to e x a m i n e this idea a n d for t h a t p u r p o s e to c o n s i d e r t h e following q u e s t i o n s : (1) W h a t is p r e v e n t i v e m e d i c i n e ? (2) By w h o m , a n d u n d e r w h a t c o n d i t i o n s , is it likely to b e practised ? (3) W h a t is likely to ~be t h e effect u p o n t h e p r o f e s s i o n i n so far as it is p r a c t i s e d b y its m e m b e r s , o r i n d e e d i n so far as it is p r a c t i s e d successfully at all ? What is Preventive Medicine? A c c o r d i n g to Sir G e o r g e N e w m a n , m e d i c i n e m a y b e d i f f e r e n t i a t e d as t h r e e f o l d in a i m ; first t h e r e is, as h e says, " The universally accepted idea of medicine as the provision of a remedy or cure for what we conceive to be disease (curative medicine) ; secondly, there is the avoidance or the prevention of its infection or causes, and when it be initiated or established, the prevention, reduction or modification of its results, or of disease-producing factors * Presidential Address to the Welsh Branch of the Society. 1944,

44

P U B L I C H E A L T H , January, 1945

(preventive medicine), which may concern individuals or may be the water engineer. I n the same manner, sewers and sewage directed to the protection of the community and the improvement of became the responsibility of the surveyor. Similarly, the its external environment, and thus be concerned with the public sanitary inspector, the health visitor, the school nurse, the health ; and tastly there is the study and practice of a way of life which conserves the natural defences of the individual or the com- school teacher, the engineer, the architect, the policeman, munity, a protection against disease associated with a favourable the social welfare officer, the newspaper reporter, and recently external environment (conservative medicine, constructive medicine the officials of the M i n i s t r y of Food, are among the host of lay workers in preventive medicine. or hygiene)."* If t h e general medical practitioner thinks he is going to T h i s division and these definitions m a y b e atl v e r y welt in gain h o n o u r or glory, m u c h less riches, by c o m p e t i n g w i t h a philosophical treatise on medicine, but I suggest they m a y these experts, he is greatly, mistaken. C d n t e m p t is m o r e likely be too elaborate, and misleading to the practising doctor. I prefer the definition given s o m e w h e r e that p r e v e n t i v e medicine to be his reward. H e m i g h t as w e l l try to c o m p e t e w i t h the patent medicine m a n u f a c t u r e r or the ophthalmic optician. is that which starts off with health and sees to its m a i n t e n But if there be those present w h o believe in t h e v i r t u e of ance, and clinicaI or curative m e d i c i n e is that w h i c h starts talk, i t will still be maintained that the doctor should be a o f f w i t h disease and endeavours to effect its cure or amelioration. teacher, that he should lighten the darkness and teU people T o call it p r e v e n t i o n w h e n one treats t h e small beginnings what to do and w h a t not to do. M u c h good m a y c o m e of of disease seems incorrect; for w h o can say at what stage t h i s - - w e have seen its effect in the cleansing of v e r m i n o u s it b e c o m e s impossible to prevent a curable disease b e c o m i n g children and in the p r o d u c t i o n of p u r e milk. T r y to persuade worse ; and w h y call that p r e v e n t i o n at one" stage w h i c h we the mental defective to remain u n d e r control, the dull n o t to do not call p r e v e n t i o n at another ? T h o s e who take this jigmultiply, the physically fit to have children, or the physically saw view of disease have failed to envisage t h e disease process unfit not to have children, and y o u are talking to the wind. as a whole. T h e y m a y soon descend to such contemptibilities as to speak of "pre-'tuberculosis" and the ' pre-tubercular," or You w a n t something more t h a n talk here to effect prevention : s o m e t h i n g w e are fighting not to h a v e - - c o e r c i o n . Is the to mistake disease for an emotional state. Likewise it is essengeneral practitioner to undertake this popular work ? O r if tially w r o n g to speak of p r e v e n t i o n because one p r e v e n t s we shift the scene and reveal the avaricious industrialist, the complications and sequelae. T h e occurrence of complications and sequelae proves that the patient has n o t b e e n completely j e r r y builder, the slum-house owner, the slum-ship owner, the food adulterator or impoverisher, is the doctor to counter c u r e d and, if they c o m e unexpectedly u p o n the doctor, t h e y the w o r k of these gentry w i t h w o r d s ? Again w e n e e d the p r o v e that he did not k n o w h i s job in that he took it for granted rather u n p o p u l a r method. But even assuming that talk could that the patient was better t h a n was really the case. accomplish all that we s o m e t i m e s fondly imagine it can, and W e are too ready to declare patients c u r e d before they are that by continuous talk at all times in season and out of season really cured, too ready to b e satisfied w i t h a low standard we m a y repeat the parable of the sower and cast some seed of cure. I do not think the shunting of the doctors' attention on good ground to grow and flourish as enlightened public f r o m the curative to the preventive aspect is likely to i m p r o v e opinion, is the individual doctor the suitable m e d i u m for this clinical acumen. O n the contrary, I think it is likely to make propaganda ? I cannot imagine he is or that he really desires t h e bad doctor a worse doctor. T h e clinician should not say, " Is this m a n well and, if so, w h a t can I do to keep h i m well ? " ; the office. I cannot believe that t h e general m e d i c a l practirather should he say " Is this m a n ill, and if so, what can I tioner desires to t u r n himself into a living gramophone record do to make h i m better ? " T h e concentration should be to keep repeating what to h i m m u s t be the same platitudes ad nausearn. I f there be any w h o consider this to be suitable on disease and not on health, for it is a less serious error, and work for the product of the m o s t lengthy and expensive p r o certainly a less cruel one, to mistake health f o r sickness rather fessional training known, I cannot share their view. I should than to mistake sickness for health. T h e great doctor is not likely to overlook prevention ; the lesser one is unlikely to have regard the school teacher, the health visitor, the public lecturer, the newspaper, the cinema, the billposter, and the wireless a mind'that will embrace prevention, diagnosis and treatment. I am surprised that the study of aetiology by the clinician as the p r o p e r media. I do not deny that the doctor should seems to be regarded as a n e w d e v e l o p m e n t . T h e elucidation play an i m p o r t a n t part in all such health education, b u t his of an aetiology m a y be a piece of original work in preventive work should be collective, not individual. I t w o u l d b e interesting to obtain the reaction of the legal m e d i c i n e ; but, the aetiology having been elucidated, it becomes part of the stock-in-trade b o t h of the clinical and of profession to the suggestion that every citizen should be prothe preventive practitioner and has been so regarded for vided with a practising solicitor or barrister to explain all legal difficulties and instruct as to h o w t h e y or complications centuries. arising therefrom m i g h t be avoided. W h o Practises P r e v e n t i v e M e d i c i n e ? W h a t is likely to be the effect on the clinical m e m b e r s of the profession of their practising prevention ? I am of opinion By w h o m and u n d e r what conditions is it likely to be pracit m u s t result in a diminished public estimation. W e do not tised ? P r e v e n t i v e medicine as I have defined it is what t h e t e r m literally i m p l i e s - - l t is really p r e v e n t i v e medicine : it is as a rule value advice we do n o t seek, and still tess are we preventive of doctoring. T h e ultimate aim o f preventive likely to r e m e m b e r it and observe it. T h e ordinary healthym i n d e d person does not w o r r y about disease tilt he is ill, medicine is to get rid of t h e doctor as well as the disease. w h e n his simple desire is to be m a d e better. W h e n he is T h i s is a point that does not appear to be appreciated by ill, he has a keen appreciation of the w o r t h of the doctor w h o m a n y m e m b e r s of t h e profession. finds out w h a t is the matter and w h o r e c o m m e n d s t r e a t m e n t All men, including doctors, m a y b e divided into two catew h i c h leads to recovery. But w h e n the doctor advises not gories : (1) those who are pioneers in the sense of making as a cure but as a precaution t h a t one should eat w h a t one is discoveries or of exciting and marshalling public opinion ; and unable to obtain, live i5 a house that has not yet b e e n built, (2) those w h o do only the routine work of their cal,iing. T h e glories of preventive medicine, in so far as they belong to abstain f r o m s o m e t h i n ~ o n e m u c h enjoys, or adopt measures w i t h respect to work impracticable to t h e individual or v e r y doctors at all, belong to doctors of the first category. I said irksome, the m o s t that can be expected is a polite appearance in so far as t h e y belong to doctors at hll, for m a n y of the greatest achievements of p r e v e n t i v e medicine are due to lay- of attention. M a n has not lived on the earth for h~ilf a million years without acquiring some perception of what is good for m e n - t o Pasteur, Ehrlich, Chadwick, Elizabeth Fry, and m a n y others. T h e pioneer w o r k having b e e n done b y doctor or h i m and what is bad. Fautty habits and tastes have a d e e p e r foundation than the shallow thinking imagine or the insincere layman, the routine preventive work is m o s t often h a n d e d pretend, and have too often arisen f r o m hard necessity. H e r e o v e r to the lay specialist or to the general public. F o r example, t h e doctor has entered a sphere where his intelligence and the pigneer demonstrated the water-borne diseases and h o w learning m a y be assessed by the patient, and, unless his reputato prevent them. T h e water supply was t h e n h a n d e d over to tion be retrieved by his clinical skill, it m a y well deteriorate. T h e public shows d e f e r e n c e for doctors of quite m e d i o c r e *The 2~iseof Preventive Medicine. Sir George Newman. 1932. p. 1,

PUBLIC HEALTH, January, 1945 ability and knowledge merely because so much of the doctors' work deals with technical matters that the public does not understand. At the best, the future must be a testing time for practitioners of medicine because of the diffusion and rising level of scientific education. Is it not strange that at such a juncture the clinical practitioner should desire to turn from clinical medicine, from diagnosis and treatment to the ordinary world of mere common sense, where the t r u e dimensions of his capabilities must be apparent to all ?

Effect of Preventive Medleine What must be the effect of preventive medicine practised in any capacity ? In so far as it is successful it m u s t lead to the elimination of the doctor, whose calling is in this respect unlike any other in that it aims at its own abolition. T h e r e are, however, many compensating factors tending to quite another result. One, very apparent, is the fact that m a n ' s battle with disease must always be a losing fight. T h e last round must inevitably be lost, and so far as I 'can see the doctor will always be needed to make the final diagnosis and sign the death certificate. Again, in the ever-changing scene o f life, new diseases on t h e one hand and injuries from new causes on the other m u s t continually arise--as, for example, the many industrial diseases and the injuries that have followed on the introduction of the motor car and the aeroplane, to say nothing of aerial warfare. Old diseases are ready to reappear as. soon as their lengthy absence has rendered them unfamiliar and made man careless. Changed circumstances may cause diseases to spread to new regions, as may yet happen to India with regard to yellow fever. With the best will in the world, preventive medicine is evidently not going to abolish the doctor for some time to come ; but that is not the fault of preventive medicine. A Conception of Medicine It will be seen that m y conception of medicine is different from that fashionable to-day. I believe that two main divisions of medicine should be maintained and clearly separated. 1. Clinical medicine concerned in the widest sense with the diagnosis and treatment of disease, and including, of course, clinical surgery, comprising among other things the diagnosis and treatment of injury. 2. Preventive medicine, social medicine, public health, industrial medicine--call it by what name you will--taking within its province the prevention of disease or injury, the maintenance and improvement of health, the improvement of the race physically and mentally---eugenics. T h e essential difference between t h e medical practitioners of these two branches of medicine should be one of mental outlook more than of differentiation of knowledge and training. T h e practitioner of clinical medicine should, of course, receive training in public health and the principles of prevention, and s h o u l d know how and when to link up with the organisation of preventive medicine, b u t his outlook should be diagnostic and curatiVe, his essential job should be to discover disease and to treat it, not to keep people well or to prevent disease. T h e practitioner of preventive medicine should have been trained in clinical medicine, and should even have attained a considerable standard of knowledge and experience in it. H e will need this as his mental background to enable him to reason, to be conscious of needs, to estimate values, and above all to place within his power the scientific use of the imagination. But all his thought must be in terms of prevention, of the maintenance of health and the improvement of the race. His functions are difficult to state briefly, preventive medicine, as I have defined it, being such a vast field with so many sections. H e is essentially the medical technician in the preventive organisation, and should exercise a stabilising and vivifying influence on the whole. One of his chief functions is to serve as a llnk between the heterogeneous workers and thinkers who form the preventive medicine army, he himself being one of these workers and thinkers. H e has to act as a policeman, as a detective, as an administrator, as an investigator, as an educator. H e has to advise, to persuade, to inspire,

45 if "necessary to arraign and to censure. Such is his relationship with the engineer, the lawyer, the architect, the schoolmaster, the sanitary inspector, the nurse, and a host of others, and in all this his thoughts are centred not only on prevention as distinct from cure, but on the human herd as distinct from the individual, for to him the individual is of small account. As the clinician should be kind and tender-hearted, for otherwise he will not be fully alive to the needs and possibilities of treatment, so should the preventive doctor be coolheaded and hard-hearted so that he may not be prone to sentimental extravaganzas. F o r instance, in a case of advanced pulmonary tuberculosis, the clinician by artificial pneumothorax and other means tries tenderly to bring the patient back to health. T h e preventive doctor says " Very good if you render h i m non-infectious, but it will serve my purpose equally well to lock him up till he dies." Or in the case of child guidance and the maladjusted child: the curatively-minded doctor says, " We must devote effort to strengthening and stabilising these children," and from his clinical viewpoint he is quite right, but the preventive doctor says, " I cannot agree that we should urge the expenditure of a tremendous amount of professional time on a small number of children, perhaps in teaching t h e m to disguise their heritable defects and helping them to transmit the neuropathic diathesis to their descendants, while we pass by in silence the non-provision of playing fields, of gymnasia and of swimming baths in schools." Have I said enough to show that there are two medicines and that they cannot be combined--at least not by ordinary men. It is, of course, open to any clinical doctor of genius to sail forth on the preventive ocean, but so it is open to one of any other calling to do likewise and to make great discoveries and bring back rich treasure. But if the commonplace clinical doctor is wise, he will leave preventive medicine to a small band of specialists in that branch of medicine and will confine himself to a sphere where none but those of his own calling can compete with him. I am sure it will be better for the clinical doctor, better for his patients, perhaps better for prevention and prevefl'tive medicine.

BOOK R E V I E W S A Synopsis of Hygiene. (Jameson and Parkinson.) By G. S. Parkinson and G. P. Crowden. 8th edition. L o n d o n : Messrs. J. & A. Churchill. 1944 Price 25s. net. Eight editions in 24 years is in itself evidence of the popularity and usefulness of any book. T h e recent publication of Jameson and Parkinson's Synopsis of Hygiene though now the production of one author, maintains the high standard of previous issues, which has earned it a place as the standard textbook for public-health students in this country. Its very excellence invites criticisms of those points which would be considered of small moment in other volumes. A feature of this book has been the inclusion of references closely linked to the subject matter. Perhaps this practice is tending to be pushed too far, resulting not only in an over-weighting of such references, b u t - - a matter of more importance--in the inclusion of references to articles not accepted as authoritative. T h e paraphrasing of official publications results in too m u c h space being devoted to relatively unimportant subjects. While the detail included in industrial hygiene is most welcome, there seems little point in devoting one and a half pages to the list of diseases coming within the Workmen's Compensation Act, and another page on silicosis. Some unfortunate student might even attempt to learn the list. While possibly of interest to the medical student, are the tables of percentages of proof spirit in beverages of such importance as to justify their insertion ? There are some small points which in future editions might be amended. Could not the list of incubation periods given in the Memorandum of to-day's Ministry of Education and Ministry of Health be everywhere accepted as standard ? T h o s e given for diphtheria (p. 41), scarlet fever (p. 48) and m u m p s (p. 56), all differ from the periods listed on p. 288. Was it really because of administrative difficulties that the notification of measles was rescinded in 1919 ? T h e state-