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SICKNESS AND THE N.H.S.
290
Annotations SICKNESS AND THE N.H.S. THE routine collection of statistics can be justified only by their usefulness either in research or in administration. In this last respect at least, the work of the Social Survey1 on behalf of the Ministry of Health is now paying its first dividends. In the heated discussions inevitable during the birth of a new health service, some cold facts may have a sedative effect. Since 1944 the lay interviewers of Social Survey have been visiting the homes of a small randomly selected sample of the adult population of England and Wales. Those interviewed are asked about their sickness experience in the previous three months, the incapacity thus caused, and the frequency of consultation with the family doctor ; and at the same time information is collected about age, sex, and economic status, so that incidence, prevalence, and incapacity rates can be worked out for the corresponding groups of the population. Similar surveys were conducted during the second six months of 1946, 1947, and 1948, and these permit comparison of the estimated frequency of illness and the calls made on general practitioners during the three periods, before and after the coming of the National Health Service. Some criticism has been levelled at this type of morbidity survey; but, so far as these simple measures are concerned, their consistency over the months suggests that their evidence is reliable. For want of better, these results can be our present guide. The monthly sickness-incidence rates-i.e., the numbers of persons reporting some illness or injury during the month per hundred people interviewed-were in 1948 almost the same as in the corresponding periods of 1946 and 1947. Closely related to these are the prevalencerates based on the numbers of sicknesses or suffered by those interviewed, and, as expected, they show little real difference in prevalence in the three periods. On the other hand, incapacity-rates, which derive from the numbers of days away from work, or (among those not employed) the number of days confined indoors, did show some significant trends. For example, among elderly women (aged 65 and over), the incapacityrate in 1948 reached the record level of 430 days lost per month by each hundred women interviewed. In general there was in 1948 an increase in the incapacity-rates of some 25% over the previous years, largely because of greater losses among women and people over 65. At least some of this increase in incapacity among older people
’
injuries
may result from a caution advised by their doctors, whom they consulted much more frequently in 1948 under the new regime. Though the consultation-rates for men between 16 and 64 changed little, womenparticularly the older ones-saw their doctors with a frequency greater by 10-26% than before. A long overdue interest in the welfare of housewives has prompted some comparisons between their sickness experience and that of other women. Direct comparisons are obscured by age differences ; but, though housewives do appear to report more frequent illness, they have fewer days of incapacity and consult their doctors no more often than do their sisters. Perhaps this might have been anticipated : when a housewife is also a mother she can seldom afford the luxury of incapacity in the sense used here. Some tentative suggestions are made that there has been an increase in the consultation-rates among the poor of both sexes, and-a little oddly-among better-off men ; but the evidence of this is still insecurely based. Enough has been demonstrated in this report, however, to quieten, the wilder statements about our national 1.
Registrar-General’s Quarterly Return for England and Wales for quarter ended March 31, 1949. H.M. Stationery Office Pp. 20 and 29.
deterioration, and at the same time to justify the claims of general practitioners that the new service has increased the demands on them. No doubt this increase would be still more obvious if children were included in the survey. It may be of interest to mention here the Government Actuary’s statement2 that since the middle of 1945 there has been a gradual downward trend in the level of short-term illness, which had risen during the war. The figures, he concludes, " suggest broadly that in the aggregate the pre-war level of short-term incapacity had been regained prior to the introduction of the new comprehensive scheme of National Insurance in July, 1948." NEOMYCIN AND TB1-698: TWO TUBERCULOCIDAL DRUGS
STREPTOMYCIN has two serious drawbacks as a chemoin tuberculosis-its neurotoxicity and the relative ease with which the tubercle bacillus can acquire a resistance to it. It was hoped that these might be overcome by the use of dihydrostreptomycin. But although this derivative is less toxic than the parent substance, it produces resistance in the bacillus. The sulphones and p-aminosalicylic acid, though useful, are less effective than streptomycin. So we must still regard tuberculosis as a killing disease for which a fully satisfactory remedy remains to be discovered. Perhaps has been more aware of the limitations of streptomycin than Waksman, its discoverer. With his team’at Rutgers University, New Jersey, he has, during thelast five years, isolated many thousands of cultures, mostly actinomycetes belonging to the genus Streptomyces, from soils, composts, peats, and other natural substrates, in the hope of finding a non-toxic antibiotic effective against the tubercle bacillus yet not producing resistance on protracted administration. These investigations have resulted in the discovery3 of a new antibiotic, named neomycin by Waksman, which appears to satisfy these criteria. The organism producing neomycin was obtained from the soil and is related to a culture isolated as far back as 1915 by Waksman and Curtis and designated as Streptomyces fradice (Actinomyces fradii). The antimedium can be removed from the-culture easily biotic in which it is grown and concentrated by the methods of adsorption and elution that have been developed for the isolation of streptothricin and streptomycin. It is a basic compound, soluble in water, thermostable, and active against numerous gram-positive and gramnegative bacteria, especially mycobacteria. The antibiotic has not yet been obtained in crystalline form and In-vitro very little is known of its chemical nature. tests and observations with hens’ eggs and mice have shown that neomycin is as active against streptomycinresistant as against streptomycin-sensitive strains of tubercle bacilli, and that it is more active than streptomycin against some strains of M. tuberculosis. Neomycin has a relatively low toxicity and so far, apparently, has not produced resistance in organisms sensitive to it. These results are indeed promising ; but its true value cannot be assessed until there is enough of the antibiotic for clinical trials. With the sulphonamides as starting-point, Domagk4 and his collaborators in Germany attempted to prepare a new series of tuberculocidal drugs derived from semicarbazide. The most effective appeared to be the thiosemicarbazone of p-acetamidobenzaldehyde, or TBI-698. Levaditi,5of the Institut Pasteur, Paris, finds that in experimental tuberculosis in mice the effect of this drug is comparable to that of p-aminosalicylic acid, though
therapeutic agent
nobody
2. Report of the Ministry of Health for the year ended March 31, 1948. Cmd. 7734. H.M. Stationery Office. 1949. Pp. 125. Waksman, S. A., Lechevalier, H. A. Science, 1949, 109, 305. Domagk, G. Dtsch. med. Wschr. 1935, 61 250. Domagk, G., Hegler. Chemotherapie bakterieller Infektionen. Leipzig, 1944. 5. Levaditi, C. Pr. méd. 1949, 57, 519.
3. 4.
Annotations SICKNESS AND THE N.H.S. THE routine collection of statistics can be justified only by their usefulness either in research or in administration. In this last respect at least, the work of the Social Survey1 on behalf of the Ministry of Health is now paying its first dividends. In the heated discussions inevitable during the birth of a new health service, some cold facts may have a sedative effect. Since 1944 the lay interviewers of Social Survey have been visiting the homes of a small randomly selected sample of the adult population of England and Wales. Those interviewed are asked about their sickness experience in the previous three months, the incapacity thus caused, and the frequency of consultation with the family doctor ; and at the same time information is collected about age, sex, and economic status, so that incidence, prevalence, and incapacity rates can be worked out for the corresponding groups of the population. Similar surveys were conducted during the second six months of 1946, 1947, and 1948, and these permit comparison of the estimated frequency of illness and the calls made on general practitioners during the three periods, before and after the coming of the National Health Service. Some criticism has been levelled at this type of morbidity survey; but, so far as these simple measures are concerned, their consistency over the months suggests that their evidence is reliable. For want of better, these results can be our present guide. The monthly sickness-incidence rates-i.e., the numbers of persons reporting some illness or injury during the month per hundred people interviewed-were in 1948 almost the same as in the corresponding periods of 1946 and 1947. Closely related to these are the prevalencerates based on the numbers of sicknesses or suffered by those interviewed, and, as expected, they show little real difference in prevalence in the three periods. On the other hand, incapacity-rates, which derive from the numbers of days away from work, or (among those not employed) the number of days confined indoors, did show some significant trends. For example, among elderly women (aged 65 and over), the incapacityrate in 1948 reached the record level of 430 days lost per month by each hundred women interviewed. In general there was in 1948 an increase in the incapacity-rates of some 25% over the previous years, largely because of greater losses among women and people over 65. At least some of this increase in incapacity among older people
’
injuries
may result from a caution advised by their doctors, whom they consulted much more frequently in 1948 under the new regime. Though the consultation-rates for men between 16 and 64 changed little, womenparticularly the older ones-saw their doctors with a frequency greater by 10-26% than before. A long overdue interest in the welfare of housewives has prompted some comparisons between their sickness experience and that of other women. Direct comparisons are obscured by age differences ; but, though housewives do appear to report more frequent illness, they have fewer days of incapacity and consult their doctors no more often than do their sisters. Perhaps this might have been anticipated : when a housewife is also a mother she can seldom afford the luxury of incapacity in the sense used here. Some tentative suggestions are made that there has been an increase in the consultation-rates among the poor of both sexes, and-a little oddly-among better-off men ; but the evidence of this is still insecurely based. Enough has been demonstrated in this report, however, to quieten, the wilder statements about our national 1.
Registrar-General’s Quarterly Return for England and Wales for quarter ended March 31, 1949. H.M. Stationery Office Pp. 20 and 29.
deterioration, and at the same time to justify the claims of general practitioners that the new service has increased the demands on them. No doubt this increase would be still more obvious if children were included in the survey. It may be of interest to mention here the Government Actuary’s statement2 that since the middle of 1945 there has been a gradual downward trend in the level of short-term illness, which had risen during the war. The figures, he concludes, " suggest broadly that in the aggregate the pre-war level of short-term incapacity had been regained prior to the introduction of the new comprehensive scheme of National Insurance in July, 1948." NEOMYCIN AND TB1-698: TWO TUBERCULOCIDAL DRUGS
STREPTOMYCIN has two serious drawbacks as a chemoin tuberculosis-its neurotoxicity and the relative ease with which the tubercle bacillus can acquire a resistance to it. It was hoped that these might be overcome by the use of dihydrostreptomycin. But although this derivative is less toxic than the parent substance, it produces resistance in the bacillus. The sulphones and p-aminosalicylic acid, though useful, are less effective than streptomycin. So we must still regard tuberculosis as a killing disease for which a fully satisfactory remedy remains to be discovered. Perhaps has been more aware of the limitations of streptomycin than Waksman, its discoverer. With his team’at Rutgers University, New Jersey, he has, during thelast five years, isolated many thousands of cultures, mostly actinomycetes belonging to the genus Streptomyces, from soils, composts, peats, and other natural substrates, in the hope of finding a non-toxic antibiotic effective against the tubercle bacillus yet not producing resistance on protracted administration. These investigations have resulted in the discovery3 of a new antibiotic, named neomycin by Waksman, which appears to satisfy these criteria. The organism producing neomycin was obtained from the soil and is related to a culture isolated as far back as 1915 by Waksman and Curtis and designated as Streptomyces fradice (Actinomyces fradii). The antimedium can be removed from the-culture easily biotic in which it is grown and concentrated by the methods of adsorption and elution that have been developed for the isolation of streptothricin and streptomycin. It is a basic compound, soluble in water, thermostable, and active against numerous gram-positive and gramnegative bacteria, especially mycobacteria. The antibiotic has not yet been obtained in crystalline form and In-vitro very little is known of its chemical nature. tests and observations with hens’ eggs and mice have shown that neomycin is as active against streptomycinresistant as against streptomycin-sensitive strains of tubercle bacilli, and that it is more active than streptomycin against some strains of M. tuberculosis. Neomycin has a relatively low toxicity and so far, apparently, has not produced resistance in organisms sensitive to it. These results are indeed promising ; but its true value cannot be assessed until there is enough of the antibiotic for clinical trials. With the sulphonamides as starting-point, Domagk4 and his collaborators in Germany attempted to prepare a new series of tuberculocidal drugs derived from semicarbazide. The most effective appeared to be the thiosemicarbazone of p-acetamidobenzaldehyde, or TBI-698. Levaditi,5of the Institut Pasteur, Paris, finds that in experimental tuberculosis in mice the effect of this drug is comparable to that of p-aminosalicylic acid, though
therapeutic agent
nobody
2. Report of the Ministry of Health for the year ended March 31, 1948. Cmd. 7734. H.M. Stationery Office. 1949. Pp. 125. Waksman, S. A., Lechevalier, H. A. Science, 1949, 109, 305. Domagk, G. Dtsch. med. Wschr. 1935, 61 250. Domagk, G., Hegler. Chemotherapie bakterieller Infektionen. Leipzig, 1944. 5. Levaditi, C. Pr. méd. 1949, 57, 519.
3. 4.