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Some points about tuberculosis in war-time
7O tunities for promotion to senior posts other than that of a medical officer of health. I n that case some reconsideration of the subjects at present required for the D.P.H. might be desirable. It might also be expedient to consider the suggestion which has sometimes been made that entry to the public health service should be by a " basic " examination and promotion to the higher posts by a senior one, to be taken after some years of practical experience, when in addition to public health generally the candidate would profess some special branch in which a high degree of proficiency would be required. These matters, however, are for future discussion. T u r n i n g to the course for the D.P.H. as we know it at present, the main question seems to be whether it should be scientific or vocational. In practice we have to aim at a judicious mixture. As the examination qualifies for posts of responsibility the training must be designed to give the candidate some competence in the routine work he will have to undertake, but it would be deplorable if it were to be regarded as purely vocational, designed only to turn out efficient office workers. I can imagine no more certain way of putting preventive medicine under bureaucratic control. If anything has to be sacrificed, I should be inclined to make vocational subsidiary to scientific training. The course requires periodic pruning. Considerable changes have been mgde recently. Much less emphasis is now laid on chemistry and physics, and no examination in practical chemistry is now required by the G.M.C. Meteorology, electrology, and radiology have disappeared as special subjects, and more emphasis is laid on the practical applications of physiology. Epidemiology is one of the most important subjects to be studied by the future medical officer, but there appear to be considerable differences of opinion as to what constitutes epidemiology. In some schools it seems to be practically restricted to the study of individual infectious diseases. I have seen papers on epidemiology which were almost entirely devoted to the clinical featur~ and treatment of fevers. This is too limited a view of the subject. How far the candidate for the D.P.H. should be trained in details of work which, in practice, is generally the province of the sanitary inspector is a debatable matter. It was natural that the Medical Officer of Health should be expected to take a keen interest in nuisances at a time when they were regarded as the usual cause of epidemics. As Scots Law stands at present it may be necessary to prove danger to health when dealing with such matters, and the medical officer has to be consulted. A revision of the law allowing nuisances to be dealt with under by-laws or regulations would permit of their being controlled by a lay officer, as it would generally be only necessary to prove that a by-law had been infringed. I n questions of housing, again, it is no longer necessary to prove injury or danger to health, but merely that a house is unfit for habitation. What constitutes unfitness is still controversial, but there seems no insuperable difficulty in fixing a housing standard which, if departed from, would permit of legal action without bringing in medical evidence at all. Traini ng for the D.P.H. in all such matters should, I suggest, be concentrated on their actual relation to health and should not condescend on technical minutiae or details of sanitary administration. The teaching of vital statistics seems to present much the same problem to candidates for the D.P.H. as to undergraduates. One is sometimes inclined to think that its main object should be to convince the student that unless he has got a real flair for statistics it is wiser to let them alone. The amount of statistical knowledge generally exhibited by candidates at examinations suggests that many teachers share this view. Public health law must, of course, be taught as a vocational subject, but might be dealt with on rather broader lines than seems to be generally the case. It is well to remember that it may entail a considerable degree of interference with individual liberty--interference which is tolerated only because the law is presumed to be justified on sufficient medical grounds. If such justification does not exist--as, for example, for some of the powers for dealing with infectious disease in the Act of 1897--the law requires amendment. This is an aspect of the subject to which the students' attention might properly be
PUBLIC HEALTH, March, 1943 directed. There is, moreover, a great body of social legislation not administered by the health authority but which has an important beating on health. A general knowledge of its scope might be more valuable than a detailed acquaintance with the provisions of individual statutes. A Plea I n conclusion, there is one other subject to which I must refer--a subject which, unfortunately, has as yet no place ifi our training. I mean history. We alone among the learned professions take no official cognizance of our past and ignore the profit and the pleasure we might acquire from its study. This is far too large a subject to tackle at the end of a paper. I merely mention it because I believe that some knowledge of the history of medical theory and of the evolution of health administration is a valuable asset even to the most neo-centric medical officer. Though we may be largely indifferent to our special share in the intellectual inheritance of mankind, we might consider, frdm a quite practical and materialistic point of view, the advantages of giving students some notion of how our branch of medicine has developed. If they are too clever to learn anything from the wisdom of their fathers they might at least gain something by studying their mistakes. SOME P O I N T S
ABOUT TUBERCULOSIS IN WAR-TIME* By JOHN G. CAIRNS,M.e., CriB. (OLAS.), D.P.H. (GLAS.). Senior Assistant M.O.H. and Clinical T.O., Portsmouth I n my own area a rise in mortality became noticeable after the outbreak of war, especially in the first quarter of 1940. There was not, however, a corresponding increase in notifications during that year. I n 1941 notifications increased considerably and the general mortality rate from the disease fell. Whether the increase in notifications was due to better diagnosis or to actual increase in the disease one cannot yet be absolutely certain. It would appear that in Portsmouth the factors which have been cat,sing an increase in the disease have been operative in the young adult age group ; this is confirmed by studying the age groups 15 to 45, in which increase is distributed equally at all ages in both sexes. Factors C a u ~ an Increase I n my opinion, two groups of factors have been operative. The first acts quickly, the second slowly. The first is analogous to the sudden strain in an individual, causing a flare up of the disease : there are three phases in our recent history during which it has become operative--first, at the outbreak of war ; secondly at the post-Dunkirk spurt in industry ; and, thirdly, during the last quarter of 1940 and the first quarter of 1941, when the city experienced heavy bombing. At the outbreak of war patients were transferred to other hospitals and to their own homes. This had a subversive influence on treatment, and the mortality rate rose in 1940. The post-Dunkirk spurt in industry was mainly a physical strain, and during the bombing period it was both physical and mental. The quickly acting group of factors corresponds to Laidlaw and MacFarlane's combination of long hours, strain of overtime, and ill-spent leisure. The second group of factors operates slowly, and the most important of these are overcrowding in houses and factories, lower hygienic standards of the home, and the mass movement of people from town to country, where the hous;ng standard may actualty be lower. Shelter life must also be included, as well as the number of " lost sight o f " cases who have infiltrated into the country districts, where overcrowding is usually present. This, possibly, is also a partial explanation of the increased number of cases among children in the country. One factor which may explain the increase in the number of cases is that doctors in wartime become ~tuberculosis-minded, and are now on the look-out for the disease. I n addition, doctors remaining in practice place more reliance on the * Abridged version of a paper read at a meeting of the Southern Branch of the Society of Medical Officers of Health in June, 1042.
PUBLIC HEALTH, March, 1943 dispensary and hospital for diagnosis. But th e important question is in the number of new cases infected rather than in the number of cases diagnosed. T h e tuberculin test is of the greatest h e l p : those who are positive can be carefully followed up and examined at frequent intervals, and the tuberculin negative contacts can be segregated. Some Wartime Problems Displacement of beds for war emergency purposes imposes on the tuberculosis officer the need for carefully selecting cases to be sent to hospital. Home circumstances should be considered in each instance, and the presence of young children should make segregation of the positive cases essential. Increased domiciliary visitation calls for an increased number of tuberculosis visiting staff. T h e inclusion of the child welfare visitors has been a successful experiment in Portsmouth, although a shortage st~ll exists. So far as diet is concerned, the Government has provided that each person obtains a sufficiency of basic foodstuffs. While the supply of extra milk to tuberculous patients is appreciated, it is unfortunate that this is not extended to an observation or suspected case. Each tuberculous patient is advised as a routine by the health visitor regarding the wise purchase of foodstuffs, e . g . , in buying the cheaper but nutritive cuts of meat. It is to be deplored that many of the cases discharged from the S~rvices were ever conscripted. In my opinion a tuberculosis officer should be on a medical board so that reference can be made to him if necessary. Shelters are supplied to tuberculous families. This is a good thing, but in an emergency tuberculous patients, in my opinion, should not be excluded from the public shelter. T h e problem of scarcity of nurses would be helped if more emphasis was laid on the importance of the work and the valuable experience to be gained in nursing tuberculous patients. Post-war Problems T h e necessary changes in administration after the war should ensure that cases notified should have their treatment directed by the tuberculosis officer. Contacts should be examined as a routine, and the law changed to give power to enforce examination if necessary. Administrative changes of this nature would produce a closer follow-up of all cases, and would be instrumental in bringing to light hidden infection. Sanatoria, suitably staffed and equipped, and large enough, will have to be built to meet the demand of the greater number of cases diagnosed. An incentive should be given to the general practitioner to supervise the patients after discharge from sanatorium. T h e present National Health Insurance fee is quite inadequate, and a capitation fee, much greater than 9s. 9d. per annum, should be granted by the National Health Insurance fund in every case of tuberculosis. A precedent exists in the mileage fee paid in sparsely populated districts for patients who reside at great distances from their doctor. Such a fee would serve two purposes. It would increase interest in the tuberculous patient and also stimulate the doctor to seek fresh cases. T h e large percentage of definite cases are advanced When referred to tuberculosis officers. One doctor told me that he would never trouble me by sending cases that were not definite. T h e principle of waiting for definite signs is wrong, and the general practitioner should be invited to send cases presenting suspicious symptoms such as night sweats, where the cause is obscure. T h e power of reporting doubtful cases might also be given to certain local government officials. Another method of bringing cases to light is by mass radiography, and it is encouraging to note that the Ministry of Health is following the example of the Services by providing facilities for this. When tuberculosis is diagnosed who is going to provide the necessary sanatoria ? T h e Government will have to solve the problem by providing suitable sanatoria to which local authorities can send cases. I suggest that a Tuberculosis Board should be formed as a branch of the Ministry of Health, which will co-ordinate and control the activities of the various regions. T h e region, in its turn, would control the administration of tuberculosis in the various local authorities. Local authorities which have built suitable sanatoria at the public expense
71 should be taken over by the Tuberculosis Board and, if necessary, be improved upon ; they would provide models for sanatoria to be built in each region. A large city should have a sanatorium (or sanatoria) for treating pulmonary cases, and an orthopaedic hospital for non-pulmonary cases. A provincial city would have its own sanatorium, and could send non-pulmonary cases to the regional orthopaedic hospital. Small local authorities could send all cases, pulmonary a n d non-pulmonary, to the regional county sanatoria and the regional county orthopaedic hospital respectively. Advantages of Re#onalism T h e words " Regional Sanatorium " should be put before the name of every sanatorium in order to stress the nature of the change in administration ; for example, " Regional Sanatorium of Portsmouth," or the " Regional Sanatorium for the Southern County." If tuberculosis has to be stamped out, it is essential that a highly trained team of officers with a Regional Tuberculosis Officer should be employed. I f the local T.O. has difficulty in disposing of a case he should refer it to the Regional Officer. This regional system conforms more strictly with the way infection spreads. Local boundaries are no barrier to the spread of infection. I n the Portsmouth statistics for 1940 and t941, lost-sight-of cases amounted to 102. Lost-sight-of cases should not occur (it is one way in which the disease is spread), and if local methods are inefficient in tracing, reference should be made to the Regional Tuberculosis Officer, and if he, in his turn, fails he should refer it to the Tuberculosis Board. Sound administrative construction should play a big part in reducing mortality rate. T h e Tuberculosis Board, with its tuberculosis officers, its regional officer, its local authority T.O., and its sanatoria, should be responsible for diagnosing and treating, but the local voluntary tuberculosis after-care committee should still serve in dealing with hardship, disability and the cases requiring rehabilitation. If the voluntary effort, is removed and replaced completely by official control patients would tend to feel themselves as cogs of an administrative machine. We must expect an increase in tuberculosis mortality, and must not relax any effort in promoting schemes which will improve the standard of the public health, but at the same time public health authorities should do what they can to further research into the chemotherapy of tuberculosis. There is a reasonable hope that chemotherapy will lead to the destruction of the tubercle bacillus in the tissues of the patient. It may come soon, it may come late, but in any case we must not relax our efforts at public health reform.
In a Ministry of Health booklet entitled " How to Keep Well in War-time" (price 3d. or 10s. for 50 copies), the people of this country are told in simple language how to keep well and in particular how to tackle the special dangers to health brought about by war conditions. It is the first time that the Ministry of Health (in conjunction with the Central Council for Health Education) has embarked on such a project. The booklet is divided into ten chapters of " golden rules to good health."
At a conference on venereal diseases held on February 26th under the auspices of the Central Council for Health Education, the Archbishop of Canterbury, President of the Council, said that if men and women would abstain from fornication the problem corlfronting the Minister of Health would be reduced to negligible proportions. This being primarily a moral problem, the object first to be aimed at was the practice of continence. The chief influence leading to this was a good home, and therefore all that could be done to promote a healthy family life, both by adequate supply of housing and by help to parents in the wise upbringing of their children, was of inestimable value. Next would come the teaching and influence of school, and of young people's associations. But far more potent than any teaching, any exhortation, any attempted compulsion, was the suggestion afforded by habits of practice and conversation and by the attitude adopted by authority.
PUBLIC HEALTH, March, 1943 directed. There is, moreover, a great body of social legislation not administered by the health authority but which has an important beating on health. A general knowledge of its scope might be more valuable than a detailed acquaintance with the provisions of individual statutes. A Plea I n conclusion, there is one other subject to which I must refer--a subject which, unfortunately, has as yet no place ifi our training. I mean history. We alone among the learned professions take no official cognizance of our past and ignore the profit and the pleasure we might acquire from its study. This is far too large a subject to tackle at the end of a paper. I merely mention it because I believe that some knowledge of the history of medical theory and of the evolution of health administration is a valuable asset even to the most neo-centric medical officer. Though we may be largely indifferent to our special share in the intellectual inheritance of mankind, we might consider, frdm a quite practical and materialistic point of view, the advantages of giving students some notion of how our branch of medicine has developed. If they are too clever to learn anything from the wisdom of their fathers they might at least gain something by studying their mistakes. SOME P O I N T S
ABOUT TUBERCULOSIS IN WAR-TIME* By JOHN G. CAIRNS,M.e., CriB. (OLAS.), D.P.H. (GLAS.). Senior Assistant M.O.H. and Clinical T.O., Portsmouth I n my own area a rise in mortality became noticeable after the outbreak of war, especially in the first quarter of 1940. There was not, however, a corresponding increase in notifications during that year. I n 1941 notifications increased considerably and the general mortality rate from the disease fell. Whether the increase in notifications was due to better diagnosis or to actual increase in the disease one cannot yet be absolutely certain. It would appear that in Portsmouth the factors which have been cat,sing an increase in the disease have been operative in the young adult age group ; this is confirmed by studying the age groups 15 to 45, in which increase is distributed equally at all ages in both sexes. Factors C a u ~ an Increase I n my opinion, two groups of factors have been operative. The first acts quickly, the second slowly. The first is analogous to the sudden strain in an individual, causing a flare up of the disease : there are three phases in our recent history during which it has become operative--first, at the outbreak of war ; secondly at the post-Dunkirk spurt in industry ; and, thirdly, during the last quarter of 1940 and the first quarter of 1941, when the city experienced heavy bombing. At the outbreak of war patients were transferred to other hospitals and to their own homes. This had a subversive influence on treatment, and the mortality rate rose in 1940. The post-Dunkirk spurt in industry was mainly a physical strain, and during the bombing period it was both physical and mental. The quickly acting group of factors corresponds to Laidlaw and MacFarlane's combination of long hours, strain of overtime, and ill-spent leisure. The second group of factors operates slowly, and the most important of these are overcrowding in houses and factories, lower hygienic standards of the home, and the mass movement of people from town to country, where the hous;ng standard may actualty be lower. Shelter life must also be included, as well as the number of " lost sight o f " cases who have infiltrated into the country districts, where overcrowding is usually present. This, possibly, is also a partial explanation of the increased number of cases among children in the country. One factor which may explain the increase in the number of cases is that doctors in wartime become ~tuberculosis-minded, and are now on the look-out for the disease. I n addition, doctors remaining in practice place more reliance on the * Abridged version of a paper read at a meeting of the Southern Branch of the Society of Medical Officers of Health in June, 1042.
PUBLIC HEALTH, March, 1943 dispensary and hospital for diagnosis. But th e important question is in the number of new cases infected rather than in the number of cases diagnosed. T h e tuberculin test is of the greatest h e l p : those who are positive can be carefully followed up and examined at frequent intervals, and the tuberculin negative contacts can be segregated. Some Wartime Problems Displacement of beds for war emergency purposes imposes on the tuberculosis officer the need for carefully selecting cases to be sent to hospital. Home circumstances should be considered in each instance, and the presence of young children should make segregation of the positive cases essential. Increased domiciliary visitation calls for an increased number of tuberculosis visiting staff. T h e inclusion of the child welfare visitors has been a successful experiment in Portsmouth, although a shortage st~ll exists. So far as diet is concerned, the Government has provided that each person obtains a sufficiency of basic foodstuffs. While the supply of extra milk to tuberculous patients is appreciated, it is unfortunate that this is not extended to an observation or suspected case. Each tuberculous patient is advised as a routine by the health visitor regarding the wise purchase of foodstuffs, e . g . , in buying the cheaper but nutritive cuts of meat. It is to be deplored that many of the cases discharged from the S~rvices were ever conscripted. In my opinion a tuberculosis officer should be on a medical board so that reference can be made to him if necessary. Shelters are supplied to tuberculous families. This is a good thing, but in an emergency tuberculous patients, in my opinion, should not be excluded from the public shelter. T h e problem of scarcity of nurses would be helped if more emphasis was laid on the importance of the work and the valuable experience to be gained in nursing tuberculous patients. Post-war Problems T h e necessary changes in administration after the war should ensure that cases notified should have their treatment directed by the tuberculosis officer. Contacts should be examined as a routine, and the law changed to give power to enforce examination if necessary. Administrative changes of this nature would produce a closer follow-up of all cases, and would be instrumental in bringing to light hidden infection. Sanatoria, suitably staffed and equipped, and large enough, will have to be built to meet the demand of the greater number of cases diagnosed. An incentive should be given to the general practitioner to supervise the patients after discharge from sanatorium. T h e present National Health Insurance fee is quite inadequate, and a capitation fee, much greater than 9s. 9d. per annum, should be granted by the National Health Insurance fund in every case of tuberculosis. A precedent exists in the mileage fee paid in sparsely populated districts for patients who reside at great distances from their doctor. Such a fee would serve two purposes. It would increase interest in the tuberculous patient and also stimulate the doctor to seek fresh cases. T h e large percentage of definite cases are advanced When referred to tuberculosis officers. One doctor told me that he would never trouble me by sending cases that were not definite. T h e principle of waiting for definite signs is wrong, and the general practitioner should be invited to send cases presenting suspicious symptoms such as night sweats, where the cause is obscure. T h e power of reporting doubtful cases might also be given to certain local government officials. Another method of bringing cases to light is by mass radiography, and it is encouraging to note that the Ministry of Health is following the example of the Services by providing facilities for this. When tuberculosis is diagnosed who is going to provide the necessary sanatoria ? T h e Government will have to solve the problem by providing suitable sanatoria to which local authorities can send cases. I suggest that a Tuberculosis Board should be formed as a branch of the Ministry of Health, which will co-ordinate and control the activities of the various regions. T h e region, in its turn, would control the administration of tuberculosis in the various local authorities. Local authorities which have built suitable sanatoria at the public expense
71 should be taken over by the Tuberculosis Board and, if necessary, be improved upon ; they would provide models for sanatoria to be built in each region. A large city should have a sanatorium (or sanatoria) for treating pulmonary cases, and an orthopaedic hospital for non-pulmonary cases. A provincial city would have its own sanatorium, and could send non-pulmonary cases to the regional orthopaedic hospital. Small local authorities could send all cases, pulmonary a n d non-pulmonary, to the regional county sanatoria and the regional county orthopaedic hospital respectively. Advantages of Re#onalism T h e words " Regional Sanatorium " should be put before the name of every sanatorium in order to stress the nature of the change in administration ; for example, " Regional Sanatorium of Portsmouth," or the " Regional Sanatorium for the Southern County." If tuberculosis has to be stamped out, it is essential that a highly trained team of officers with a Regional Tuberculosis Officer should be employed. I f the local T.O. has difficulty in disposing of a case he should refer it to the Regional Officer. This regional system conforms more strictly with the way infection spreads. Local boundaries are no barrier to the spread of infection. I n the Portsmouth statistics for 1940 and t941, lost-sight-of cases amounted to 102. Lost-sight-of cases should not occur (it is one way in which the disease is spread), and if local methods are inefficient in tracing, reference should be made to the Regional Tuberculosis Officer, and if he, in his turn, fails he should refer it to the Tuberculosis Board. Sound administrative construction should play a big part in reducing mortality rate. T h e Tuberculosis Board, with its tuberculosis officers, its regional officer, its local authority T.O., and its sanatoria, should be responsible for diagnosing and treating, but the local voluntary tuberculosis after-care committee should still serve in dealing with hardship, disability and the cases requiring rehabilitation. If the voluntary effort, is removed and replaced completely by official control patients would tend to feel themselves as cogs of an administrative machine. We must expect an increase in tuberculosis mortality, and must not relax any effort in promoting schemes which will improve the standard of the public health, but at the same time public health authorities should do what they can to further research into the chemotherapy of tuberculosis. There is a reasonable hope that chemotherapy will lead to the destruction of the tubercle bacillus in the tissues of the patient. It may come soon, it may come late, but in any case we must not relax our efforts at public health reform.
In a Ministry of Health booklet entitled " How to Keep Well in War-time" (price 3d. or 10s. for 50 copies), the people of this country are told in simple language how to keep well and in particular how to tackle the special dangers to health brought about by war conditions. It is the first time that the Ministry of Health (in conjunction with the Central Council for Health Education) has embarked on such a project. The booklet is divided into ten chapters of " golden rules to good health."
At a conference on venereal diseases held on February 26th under the auspices of the Central Council for Health Education, the Archbishop of Canterbury, President of the Council, said that if men and women would abstain from fornication the problem corlfronting the Minister of Health would be reduced to negligible proportions. This being primarily a moral problem, the object first to be aimed at was the practice of continence. The chief influence leading to this was a good home, and therefore all that could be done to promote a healthy family life, both by adequate supply of housing and by help to parents in the wise upbringing of their children, was of inestimable value. Next would come the teaching and influence of school, and of young people's associations. But far more potent than any teaching, any exhortation, any attempted compulsion, was the suggestion afforded by habits of practice and conversation and by the attitude adopted by authority.