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Some problems in maternity and child welfare work
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PUBLIC
HEALTH.
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S o m e P r o b l e m s in M a t e r n i t y Welfare Work.
and Child
By ELWIN H . T . NASH, M . R . C . S . , L . R . C . P . , D . P . H . , Medical Officer of Health and School Medical Officer, Heston and Isleworth.
l)r. Nash has devo~.ed m~ch attentio,n to maternity and child welfare work, and in this, his Presidential Address to the Maternity and Child Welfare Gro~@--one of lhe most active within the Society--he mentions many o/ the problems still to be surmounted, and offers suggestions for overcoming them. N discussing t h e present position from the
I po.int of view of administration of maternity and child welfare it is well to look back and see the development of the work from its inception, Maternity and child welfare work--like a good man y others--was first pushed in this country by enthusiastic voluntary workers, and ultimately carried on by municipal ~ffort, and now the majority of the clinics are municipal, the whole of the funds being supplied from the rates. T h e r e are, however, still a very large number of centres in the bigger towns, particularly London, on a voluntary basis, receiving grants from municipal funds, but controlled entirely by voluntary wo.rkers, Some of these have done, and are still doing excellent wo.rk, although reports from some of the medical officers at such centres do not indicate that their work has the freedom that it has under municipal control. It is probably owing to the predominance of the voluntary worker in the begi nni ng that the voluntary worker exists to such a large extent as a necessary adjtmct to the successful carrying on o.f the infant welfare clinic, thus reducing the expense of staff which would otherwise fall on the local authority, Maternity and child welfare work is peculiar in that it is inspected entirely by a female staff, and still further peculiar: in that it is-ds f/ii:~as I arrl a w a r e - - t h e 0nly branch ~of municip/tl NedicM work which is inspected by nonmedical officers. T hi s would ap~pear t o tend col0ur ~o 'the idea thg[t maternity" affd~child welfare work is a peculiar prerogative of the female sex. Th'is, in my opinion, is a mistake and a serious mistake. It does no.t necessarily follow that a single woman, because she is a woman, is more capable of dealing with or mdfe interested in the child than a single man, still less than the married man. There are medical officers of both sexes who have that invaluable quality of a natural apti-
tude for dealing with a child, which is accompanied by a natural affection for children. T h e r e are also members of both sexes who are quite incapable of coming down to the c h i l d ' s level, and personally I feel very strongly that it is a great mistake to postulate - - a s practically all the voluntary centres that I know d o - - t h a t a woman is the only perso.n who can efficiently work a maternity and child welfare clinic. T h e position of the maternity and child welfare officer is peculiar in that it is the only branch of municipal health work which is largely staffed with part-time female officers, and in so. far as the part-time officer is enabled to do other work in additio.n to a number of clinics, paid at so much per session, she is able to earn a proportionately much larger income than a whole-time officer. Ttiere is another peculiarity about the maternity and child welfare work in the position it holds with regard to the future of whole-time officers of the male sex. In the early days of public health work, when medical inspection of school children commenced, experience in that direction was regarded as a very large asset and counted as a considerable stepping-stone towards promotio.n to the higher administrative posts. Nowadays a clinical knowledge of tuberculosis, for some unknown reason, appears to be considered the most important item as exemplified by more recefit' appomtments~ to the ~hole-time senior administrative posts. For what reason I am entirely at a loss to. understand, as if there is ~ n e s~fvice to/rr~y mihd which is more important to the country at the present time and which shows better value for money spent it is maternity and child welfare work; and yet, things being equal in other respects, the tuberculosis officer gets the pull almost ever), time. If the value o.f results counts for anything the tuberculosis service certainly has not the first claim as its members admit that its results are discouraging. T h e r e is no one -
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w h o has experience of b a c t e r i o l o g y in a public health d e p a r t m e n t w h o does not know that they are not g e t t i n g to the root of the trouble. It is c o m m o n k n o w l e d g e to all who d o the work how great a n u m b e r of specimens sent in for the first time are s w a r m i n g with tubercle bacilli. As a public health administrator there is no question in m y mind of the c o m p a r a t i v e i m p o r t a n c e of the two kinds of work. T h e r e is a n o t h e r idea which seems fixed in so m a n y people's minds, bo.th municipal and a p p a r e n t l y State, that the single women who. constitute a large p r o p o r t i o n of the maternity and child welfare officers of the present d a y are specially qualified b y reason of their sex to deal with ante-natal work a n d to deal with the m o t h e r s and the p r o b l e m s which arise in married life. W h i l s t not e x p r e s s i n g a n y political opinion as to the e m p l o y m e n t of married women, there is surely no branch of work in which t h e e m p l o y m e n t of married w o m e n - - a s c o m p a r e d with the single women - - i s of such e n o r m o u s a d v a n t a g e . T h e r e is no d e n y i n g the fact that married life is to. a large extent a closed book to the u n m a r r i e d , as closed as f r e e m a s o n r y to those who do not b e l o n g to the craft, a n d the fact that the officer is still single m e a n s that she has not yet experienced that most wonderful t h i n g which is the basis of all married l i f e - the mutual love of a m a n a n d w o m a n . T h e u n m a r r i e d w o m a n c a n n o t enter into and discuss the details of married life in the same way as a married w o m a n or married man can. T h e y are m u c h in the position of T o m l i n s o n , as described b y K i p l i n g , who, after he had v a i n l y a t t e m p t e d to gain admission to Hell, a n d h a v i n g been refused, applied at the gates of H e a v e n , a n d was there dismissed with utter scorn on the g r o u n d of inadequate knowledge, with the p a r t i n g words : " A n d the G o d that you took from a printed book be with you, T o m l i n s o n . " : their k n o w l e d g e is incomplete. At present in m a n y o,f the larger districts the work is cut up into special d e p a r t m e n t s with a t e n d e n c y to a p p o i n t an officer to do school work and an officer to do m a t e r n i t y and child welfare work, and in the discussions which have taken place recently there is that drawback which so often arises, viz., that the individuals discussing the subjecc will o n l y discuss it in terms of the office they hold and not in the larger sense o f the c o u n t r y at large. In large centres like L o n d o n , B i r m i n g h a m and M a n c h e s t e r things are quite different from
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the smaller areas existing, and areas which are arising, which form the great majority of administrative units. W i s e l y u n d e r the advice of the M i n i s t r y of I I e a l t h the union of districts is b e i n g b r o u g h t about to create, whole-time single unit areas. T h e r e is a tend e n c y when these grow, and extra assistance is required, as far as one can see, in the first place to get the extra assistance required for m a t e r n i t y and child welfare work on a parttime basis. T h e r e is also a t e n d e n c y in some of the larger towns fo.r some of these part-time maternity and child welfare officers to attempt to specialise entirely in infant feeding. \Vhilst specialisation is alright up to a certain point there is, I think, infinite h a r m both to the cause and to the individual in m a k i n g that specialisation too narrow. T h e r e is a great d a n g e r to m y mind in specialising in work in which a large n u m b e r of the cases seen require practically no medical t r e a t m e n t or advice, as in child welfare work and School medical inspection. In ordinary specialisation at a hospital the cases which present themselves fo.r treatment and observation are in e v e r y case d e p a r t u r e s from the normal and, from that point of view, full of interest. F u r t h e r , if y o u take the people who are specialising in c h i l d r e n ' s work, whose n a m e s in their v a r i o u s districts c a r r y the weight o.f authority, you will find that all of them have the wider interests of a c h i l d r e n ' s hospital with all the manifestations of c h i l d r e n ' s disease and its treatment, or of some other h.ospital. T h e n a r r o w specialisation such as is offered by infant welfare work and similar kinds of work t e n d s to p r o d u c e in course of time a slackness of m i n d a n d an a u t o m a t i s m which is not f o u n d where the interests are wider. As far as infant welfare work is concerned, to those d e v o t i n g themselves ~to that class o.f work there would a p p e a r to be comparatively l i t t l e . f u t u r e . C o m i n g now to the more i m p o r t a n t questio.n of the clinic, one of the administrative difficulties is the n u m b e r of patients that should be seen by the medical officer, m y own feeling b e i n g that a b o u t t w e n t y is the n u m b e r which gives the best result. S p e a k i n g to a medical officer of a clinic some while a g o I received the following reply : " A f t e r twenty m y enthusiasm dies r a p i d l y . " M y own experience coincides entirely with that statement. L a r g e n u m b e r s tend to spoil the work by d i m i n i s h i n g the time which should be given to parents, and the parents in turn feel that if the work is of
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such little impo.rtance that it has to be scrambled through, they are not going to pay the same attention to the advice given as if it appears to be of such importance to the local authority that adequate premises and staff are provided and sufficient time is allowed for carrying" out the work. It is difficult to assess the average attendances which should produce an average of about twenty to be seen by the medical officer, and it would be interesting" to. find what are the opinions of the various officers carrying out the work with regard to that. T her e is another administrative diffÉculty which varies in different districts; this is as to whom shall the attendance at the clinics be limited. In some districts a wage limit is apparently fixed with the idea that it is only the very poor who want advice with regard to br i ngi ng up their children. As far as my experience goes, ignorance with regard to the u p b r i n g i n g . o f children is not the prerogative of any class from the highest to the lowest. T h e r e is a very definite difficulty at present in many districts around L o n d o n with regard to. t h e influx of a new population whose finances would on the surface appear to be such that they can easily afford medical attention by their private doctor. A large proportion of these are buying their houses under assisted schemes and have little or no margin, and even if there is a margin, that m a r g i n is rapidly diminished to vanishing point when there is any continued sickness, which means substantial doctor's bills. It is those of us who are actually doing maternity and child welfare work and who know the conditions under which the people live, who realise that the majority of them cannot p a y for much medical attention. W h a t usually happens, then, is that if they -are refused at the clinic the child's little ailments are allowed 63 go. without skilled attenti0n q r. it'dvice. Such advice as !s~..given is general!y of the wrong kind, particularly .if" given by either of the mothers-in-law, and it is not until the chitdoh~s qSdety.,dep~rted~;#rom the normal and is really ill that they feel that they must s p e n d the necessary amount on medical advice. I am now g e t t i n g into my clinic a class Which I never had befo.re, partly I think owing to. financial circumstanges, partly I find due to the realisation that they get advice as a rule in the maternity and child welfare clinic which is not available elsewhere.
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H a v i n g been in general practice for eight years before coming into public health, I can speak from experience with respect to the general practitio~ner. It is not. the fault of the older ones that they received no teaching whatever with regard to infant welfare work and infant feeding. Tile relative importance which was attached to this large subject has to be gauged by the fact that it is onl y within quite recent years that a single question on child welfare and infant feeding or even pediatrics as such was considered necessary in the qualifying examination o.f the medical student. T h e r e is, as a result, amongst many of the older practitioners a want of appreciation as to what is being done and can be done in a n infant welfare clinic. In some cases there is ,definite hostility, which I think is a pity, but I think that there may be grounds for some of this in the way that some clinics undertake treatmenl. Some general practitio.ners feel that work is being taken out of their hands, and the sphere of usefulness of the general practitioner is being narrowed by the work carried out in the municipal clinics. I, perso.nally, should say that instead of that, the clinics both maternity and infant welfare and school are responsible for sending to the the general practitioner cases which he would never get otherwise. [n order to keep the goodwill of the practitioners of my own district, I do not undertake any treatrnent whatever except that strictly limited to dietetic corrections, and the simplest possible matters bordering .on them, and this I believe is the general policy. Another difficulty that clinics have to. face is a want o.f consideration on the part of physicians in charge of some of the infant welfare departments of the larger hospitals for the maternity and child welfare officer working in the clinics. Many of these medical officers-are,persons of wide experience in this particular branch, o.f 'work, and it is galling t o a degree to send a case to a hospital fo.r spjne r.eason other than dietetic,, when the child is being k e p t on a certain kind of diet for some satisfactory reason, to have t he child sent round to the hospital infant welfare department where the physician in charge orders an entirely different method of feeding, and later the medical officer at the clinic gets a letter from the hospital authorities to the effect that tt~e child has been placed under the control of Dr. X, who has ordered the
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child such and such a diet and would the medical officer at the clinic see that it is provided. T h e medical officer in return for such want of consideration will take very good care that no patient is ever advised to attend that hospital again. T h e r e is, unforttmately, a want of co-o.rdination between m a t e r n i t y and child welfare work as carried on b y the municipal authorities and the v o l u n t a r y hospitals on the one hand and the p o o r law authorities on the other. In the big towns there is the difficulty that the c h i l d r e n ' s hospitals a r e so far from the homes o.f the people, and in the smaller towns so. far from the h o m e in the c o u n t r y areas, a n d here a g a i n there is the e x t r a o r d i n a r y want of u n d e r s t a n d i n g a m o n g s t some of the hospital p h y s i c i a n s and a m o n g s t the j u n i o r officers as to the financial capabilities of the patients wlno come to. them. It is not u n c o m mon, as e v e r y medical officer either to a centre or a school clinic in the greater I . o n d o n area will bear out, fo.r a patient who has been to a hospital to return with the message that Dr. X wants them to go twice a week. We have sent them up for advice; m u c h of the treatment, if not all, could be carried out in connection with the clinic, and what does twice a week mean to these u n f o r t u n a t e parents ? F r o m the outside ring of L o n d o n or even in our provincial towns, c o m i n g in means a substantial expense. T r a i n fares from the outer ring of Lo.ndon m e a n 1/6 if the child goes free, if not, a n o t h e r 9d. In order to get to the hospital for the afternoon out-patients, it means leaving before 11 in the m o r n i n g , g e t t i n g away about 3.,30 to 4 in the afternoon a n d h o m e about 5.30 p . m . or later. As often as not a b a b y has to be taken if the toddler is the p a t i e n t ; this all m e a n s a payment of about 2/3 plus the cost of any food, and a m o t h e r dead beat b y the end of the day. I n v a r i a b l y when I ask a m o t h e r w h y she has not attended the hospital again, the reply is : " It's no use, doctor, I simply c a n ' t affo.rd i t . " At times I find a m o t h e r g o i n g short in order to get the m o n e y for the fares. O n e of m y most decent little mothers d u r i n g a conversation s a i d : " Y o u know, doctor, before the war I made a point of s a v i n g 3d. every w e e k . " H o w much is c o n v e y e d in that ; insolvency plus ~3d. equals solvency ? T h e r e must be provided, b y some m e a n s or other, greater facilities for s e n d i n g cases for further treatment and advice in the neighb o u r h o o d of the clinics. For instance, in
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L o n d o n there is a definite s h o r t a g e of children's hospitals in the outer ring. I say c h i l d r e n ' s hospitals advisedly because, speaking from m y o,wn experience in hospital work I a m convinced that the best c h i l d r e n ' s work is done in a hospital devoted entirely to children. T h e r e is, if one m a y say so, a h i g h e r standard of k n o w l e d g e and a different atmosphere of u n d e r s t a n d i n g of the clnild botti b y the medical staff a n d nurses, in hospitals devoted entirely to. children, in contrast to the hospitals where the c h i l d r e n ' s section is o n l y a small p r o p o r t i o n of the work. A problem which is often b e i n g b r o u g h t up is the question of the financial status of people who should be supplied with the dried milks and such like things at the clinics at the reduced prices at which the clinics a r e a b l e to sell t h e m as c o m p a r e d with the prices c h a r g e d in the shops. Certain proprietors of infant foods have no.t been above c o m p l a i n i n g to the Go.vernment d e p a r t m e n t s that their sales are seriously prejudiced b y the s u p p l y of dried milks and other t h i n g s at costs below which their p r o d u c t s are retailed in the shops. W e are pestered b y the representatives of this and tlnat particular article, w h o claim for their preparation qualities possessed by no other. E v e r y public c o n v e y a n c e flaunts the claims of some patent food. It is a c c o m p a n i e d by alluring pictures of some comely maid who is administering to the ailing, or illustrations of some child who would have do.ne equally well on some other food or even on its own m o t h e r ' s lnilk. P e r s o n a l l y , i am v e r y loath to utilise widely advertised articles of diet. It would be a great i m p r o v e m e n t if, b y some m e a n s or other, local authorities would combine to m a n u f a c t u r e s t a n d a r d milks for use in their clinics. H o w m a n y people realise what it means to feed a child on these p r e p a r a t i o n s at the prices which are c h a r g e d for them ? A s~mrt-.'dme a g o a new m o t h e r came in who. had been put on one of these p r e p a r a t i o n s b y ' h e r general practitioner, a n d had o n l y come to the clinic because she said she s i m p l y could not afford to carry on a n y longer. S h e was now getting" into the fourth tin a week, and the cost would then be 10/- per week. If people would only think for a m i n u t e that that represents the g r e a t e r - p a r t of the house rent for the entire family, it would give them some sense of proportion when dealing with these things. O n l y c o m p a r a t i v e l y recently at a clinic in ,the greater L o n d o n area a m o t h e r came in and asked the
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medical officer for a certain widely advertised article of infant food, and was told that they did not supply it. After she had left the traveller for that particular article of food asked to see the medical officer, and demanded to know why their food was n o t stocked; the whole thing obviously being a put-up job. T h e n there is the question of milk supply. W e who use large quantities of dried milk are railed at b y the clean milk purist on the grounds that we make a supply of dirty milk easier by not encouraging the demand for clean wet milk. I think I am right in saying that the general experience is not such as to encourage the supply of wet milk fo.r infant feeding. T h e poorer mothers cantmt afford the higher priced grade " A " or certified milk, and even if the milk is pasteurised there is no question fis to the superiority of the dried milk from a safety point o.f view. Personally, I am unrepentant, tt is the i:arest thing for me to use wet milk if I have to feed artificially. Another difficulty is that of getting in touch with the ante-natal cases. T h e reasons are, I think, partly that the women are not yet educated up to attending the ante-natal clinic, and further I am convinced that the presence of municipal midwives is a very definite bar to their attendance, due to the fact that the midwives of the district have a f e e l i n g - - a n d in some cases not without cause - - t h a t if their patients attend the ante-natal clinic they are likely to have pressed upon them the value of the municipal midwife's attentions, and thus lose their patients. I believe that where there is difficulty with adequate midwifery services the best results are obtained by subsidising competent midwives so that they c a n make a living rather than attempting to appoint a municipal midwife. Difficulty also arises where there is a municipal maternity home as to the class.of pat!ent "~ho shall be' 'admitted. It should be, ifl I.n) opinion, a fundamental point that no patient should be ~dmittedo wt3o2-ha~, no~atten~t~ed an ~nte-natal ctinic or can produce d derf{i~cate fro.m her medical practitioner that she h a s been examined a t least twice within the last four months, thus ensuring that ante-natal supervision which means so much towards the warding off of diNculties later on. ~:hen again there is the difficulty of admitting the*emergencies that have arisen during confinment outside. My own opinion is that these cases should be resolutely refused, and
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should be sent elsewhere, as it is n o t right that a mother who goes into the municipal maternity home postulating a safe confinement should be exposed to. the risk of infection brought in by someone who has not taken the same precaution as she has to" ensure a satisfactory confinement. Another difficulty is the staff necessary to run satisfactorily a well-attended clinic. T h e maternity a n d child welfare work is the only branch of public health activity where vo.luntary workers are advocated as members of the staff. T h e Ministry assess the necessary health visito.rs at 1 to every 300 births. T h e r e must, however, be wide variations in the demand owing to the differences in the residential character of tile area e m p l o y i n g them. T h e voluntary worker can be and very often is an invaluable adjunct to tile clinic, provided that they are content to do the work allotted lo them witho.ut attempting to interfere with the professional side of the work. Voluntary workers m a y be divided into two classes of work. T h e leisured class and those who do not belong to the leisured class. T h e r e are those who really understand the responsibilities attached to the work. T h e r e are others, however, who do not, and who allow their social calls to interfere with the responsibilities they have assumed. T h e r e are still many of these people who do not really understand the conditions under which the poor live. W i t h i n the last month a case was brought to m y knowledge by one of the voluntary workers in a very poor district, where the wellmeaning voluntary committee r u n n i n g the centre, of which she was a member, suggested that a demonstration on washing and bathing the baby should be given to the mothers on a Friday, and either ad. or 6d. be charged for admission. T h i n g s begarr to get quite uncomfortable, when the member who visited the poor ~and really understood their needs pointed out the f.utit~ty o f the suggestion, first on the g r o u n d of the fee for admidsio.n and secondly on the .ground that Friday was pay ~fay, "and tla/it .hntit l~riday evening" there was no money in the house. It was then suggested that the demonstration should t a k e place on a Monday, and things got more uncomfortable whela the same member, with a knowledge of conditions, pointed out that M o n d a y was washing day. W i t h the non-leisured class I have been singularly fortunate in those who have volunteered for service in m y various clinics, and I record with deep gratitude their
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devoted services week in, week out, and in some cases year after y e a r . W i t h respect to the poor law, there is also want of close co-ordination. For instance, recently a m o t h e r was admitted to the local hospital with eclampsia the d a y after her confinement. T h e father made an application for assistance in the matter of food for the children next day. t i e was in great difficulties; one n e i g h b o u r had taken both children d u r i n g the day, but h a v i n g her h a n d s so full she was o n l y able to take one at night, the other b e i n g taken b y a n o t h e r n e i g h b o u r . I pointed out that in the c h i i d r e n ' s interests there was o n l y one t h i n g to do, and that was to get them admitted at once to the local poor law institution. T h i s he a t t e m p t e d to do, but was met with the reply that it was impossible to admit the children unless he went in too. T h e man at the time was out of wo.rk, but surely there is s o m e t h i n g lacking in our m a c h i n e r y which refused to do what is necessary for the children without c o m p e l l i n g the h u s b a n d to enter the workhouse. T h e r e s h o u l d also., I think, be closer co-ordination between the p o o r law and the m a t e r n i t y and child welfare centres, so that if it is recognised that the centres are the places where special care can be taken of children, parents in receipt of poor law relief could be referred to the clinics, and an a r r a n g e m e n t made w h e r e b y the cost of the food for their children was paid b y the guardians. T h e r e is a n o t h e r difficulty which is constantly c r o p p i n g up, namely, the g i v i n g of s t a n d a r d advice b y means of leaflets. T h i s has been p u t before this G r o u p for consideration and u r g e d b y certain other societies interested in c h i l d r e n ' s work. M y own feeling is that it would be a grievous mistake to standardise advice when so m a n y are getting" the same results b y using" different methods. T h e r e is m u c h more likelih(~od of advice b e i n g followed if it is given by a medical officer than if a palnphlet is simply h a n d e d over and the m o t h e r is told to follow the directions on the printed leaf. W h a t of the future ? Is m a t e r n i t y and child welfare work to stay as it is at p r e s e n t - - a water-tight division in the child's life, or is it to become part of a unified whole, dealing with the child from the cradle till the time it is taken over b y the autho.rities dealing with the I n s u r a n c e Acts ? T h e i m p o r t a n c e which was attached to school medical work in years g o n e b y has now
HEALTH.
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passed to the pre-school child who is u n d e r the care of the m a t e r n i t y and child welfare centres, and we are more and more realising that the a g e - g r o u p which has to be co,ncentrated on is the one which is now missing the necessary medical supervision v e r y largely, n a m e l y the child from 2 to 5. Sir G e o r g e N e w m a n is c o n s t a n t l y r e f e r r i n g to the p e r c e n t a g e of entrants into our schools with defects which m i g h t have been remedied some considerable time before c o m m e n c i n g school. It is difficult at present to say how that ageg r o u p can be dealt with except on the lines of persuasion, i t will be, I think, for some time mainly b y the activities of tactful health visitors that this a g e - g r o u p will come u n d e r medical supervision, b u t in order to do our d u t y b y them we must have all the necessary facilities for dealing" with m i n o r a i l m e n t s - - e a r troubles, eye troubles a n d such like, in addition to the facilities which we now possess for o b t a i n i n g dental t r e a t m e n t . H a v i n g got those it is illogical to expect an entirely separate m a c h i n e r y to be dealing with children below 5 and over 5, possibly from the same house, suffering from the defects which the clinics are able to deal with. M y own feeling is that, speaking of the c o u n t r y generally, the best results are g o i n g to be obtained not b y too great specialisation, but b y the unification of maternity and child welfare work with the o thei- public health services, both as r e g a r d s the medical p e r s o n n e l a n d the n u r s i n g personnel. As an illustration an able health visitor, who had experienced both classes of work in her own district, said to me quite, recently : " W h e n I was g o i n g into a house whilst d o i n g both kinds of work, I knew all the family, went as a friend of the f a m i l y a n d had much greater ease in g e t t i n g t h i n g s remedied than I have now w h e n I g o in s i m p l y as a school nurse a n d am a complete s t r a n g e r to a large n u m b e r o f the f a m i l y . " In most o f , the c o u n t r y areas the medical, officers will be c a r r y i n g out all the duties of the s~ho.ol medical service a n d maternity., a n d child welfare work in their own allotted area. T h e r e should be this closer Co-ordination referred to with the local hospitals o.n the one hand, who are in a position to. give the skilled attention or advice required, a n d the poor law institutio.n on the other, a n d we m a y possibly see in the revisio.n of the poo.r law services some definite advances in that direction. W i t h r e g a r d to the .staff in the clinics there will p r o b a b l y be for m a n y years to come a
t928.
21
P U B L ~ HEALTH.
supply of helpers which we tind at present so necessary to eke o.ut the professional assistance. There is some compelling force about the infant which draws into the clinics a sufficient number of helpers who are not in the least attracted towards work amongst adults or even older children. I think, too, as we find persons from a higher social and financial status making use of the State-supplied schools there will be, if the maternity clinics keep up the necessary standard of work, a definite inclination on the part of some of these people to utilise the services of the clinics staffed by the officers of the local authority. Nor do I see quite how it is going to be logical to exclude these people so long as
The
they are at liberty to make free use of the State-supplied schools. There will probably, therefore, be some move on the part of the general practitioner to establish some sort of boundary line in the same way as has been established in the Ihsurance ~cts, but it is not likely, in my opinion, to carry a n y t h i n g like the same weight as it might do so long as the clinics are carried on as the majority are at present. As I pointed out before, they do not take work from the general prac.titioners, but actually put wo.rk into their hands, as in the majority of clinics, as soon as ever a child can be called ill, it is sent post haste to its own medical adviser or to the poor law o.r hospital as the case may be.
Private Practitioner the Pflblic Health.
and
By S. Fox LINTON, M.Sc., M.D., D.P.H., Medical Officer of Health, Scarborough.
The recognition of the importance of the relation between the private practitioner of medicine and public health is general, and the suggestions of Dr. Fox Linton, contained in his Presidential Address to the Yorkshire Branch, on February 24th, 1928, as to how it may be ensured and strengthened, are worthy of serious consideration. ET us consider a problem which is assuming L greater and greater prominence as the importance of personal hygiene comes to be more and more recognised as equal to that of environmental hygiene. By what means can private practitioners best be enabled to take their proper share in the preventive medicine of the future, associating themselves more closely:with official preventive agencies and carrying into the homes of their patients the ideal of prevention rather than of cure ? Nowhere yef has a complete scheme been devised for basing the whole fabric of personal and domestic hygiene on its proper foundation--the medical practitioner, but some" attempts. have" been ma.de. In Australia, for example, some initial steps h'ave been taken with tl~e object of lncFtgdmg the general practitioner as a working element in the public health system. Since 1921, the Commonwealth • Director-General of Health has made a practice of attending the bi-annual meetings of the British Medical Association in Ausf;alia, on each occasion taking the opportunity to 'have an unofficial talk with representatives of the Association. This has resulted in a nmch closer association between the
official departments and the controlling body of the medical profession, and a keener consideration by the profession of its individual responsibility in matters of public health administration and possible reform. The British Medical Association in Australia has accordingly drawn up a statement for the consideration of the whole profession of which the following is a short outline: ..... After emphasising the desirability of linking up the general practitioner into active participation in the administrative scheme, it suggests .that his preventive "work, in addition to notification of births, still-births, miscarriagds, ffeaths, infectious di~seases and cases of mineral and org~inic (alcoholic, etc.) poisoning, should include the ordering of prescribed rh~thods of. disinfection in infectious cases, the taking of swabs and other specimens for the detection of carriers, the examination of school children in particular districts (i.e., in country schools), and other duties as prescribed from time to time by regulations or as requested by the health officer. The practitioner is to receive fees for all such work. The Director-General of the Commonwealth, giving evidence before a Royal Commission
PUBLIC
HEALTH.
15
S o m e P r o b l e m s in M a t e r n i t y Welfare Work.
and Child
By ELWIN H . T . NASH, M . R . C . S . , L . R . C . P . , D . P . H . , Medical Officer of Health and School Medical Officer, Heston and Isleworth.
l)r. Nash has devo~.ed m~ch attentio,n to maternity and child welfare work, and in this, his Presidential Address to the Maternity and Child Welfare Gro~@--one of lhe most active within the Society--he mentions many o/ the problems still to be surmounted, and offers suggestions for overcoming them. N discussing t h e present position from the
I po.int of view of administration of maternity and child welfare it is well to look back and see the development of the work from its inception, Maternity and child welfare work--like a good man y others--was first pushed in this country by enthusiastic voluntary workers, and ultimately carried on by municipal ~ffort, and now the majority of the clinics are municipal, the whole of the funds being supplied from the rates. T h e r e are, however, still a very large number of centres in the bigger towns, particularly London, on a voluntary basis, receiving grants from municipal funds, but controlled entirely by voluntary wo.rkers, Some of these have done, and are still doing excellent wo.rk, although reports from some of the medical officers at such centres do not indicate that their work has the freedom that it has under municipal control. It is probably owing to the predominance of the voluntary worker in the begi nni ng that the voluntary worker exists to such a large extent as a necessary adjtmct to the successful carrying on o.f the infant welfare clinic, thus reducing the expense of staff which would otherwise fall on the local authority, Maternity and child welfare work is peculiar in that it is inspected entirely by a female staff, and still further peculiar: in that it is-ds f/ii:~as I arrl a w a r e - - t h e 0nly branch ~of municip/tl NedicM work which is inspected by nonmedical officers. T hi s would ap~pear t o tend col0ur ~o 'the idea thg[t maternity" affd~child welfare work is a peculiar prerogative of the female sex. Th'is, in my opinion, is a mistake and a serious mistake. It does no.t necessarily follow that a single woman, because she is a woman, is more capable of dealing with or mdfe interested in the child than a single man, still less than the married man. There are medical officers of both sexes who have that invaluable quality of a natural apti-
tude for dealing with a child, which is accompanied by a natural affection for children. T h e r e are also members of both sexes who are quite incapable of coming down to the c h i l d ' s level, and personally I feel very strongly that it is a great mistake to postulate - - a s practically all the voluntary centres that I know d o - - t h a t a woman is the only perso.n who can efficiently work a maternity and child welfare clinic. T h e position of the maternity and child welfare officer is peculiar in that it is the only branch of municipal health work which is largely staffed with part-time female officers, and in so. far as the part-time officer is enabled to do other work in additio.n to a number of clinics, paid at so much per session, she is able to earn a proportionately much larger income than a whole-time officer. Ttiere is another peculiarity about the maternity and child welfare work in the position it holds with regard to the future of whole-time officers of the male sex. In the early days of public health work, when medical inspection of school children commenced, experience in that direction was regarded as a very large asset and counted as a considerable stepping-stone towards promotio.n to the higher administrative posts. Nowadays a clinical knowledge of tuberculosis, for some unknown reason, appears to be considered the most important item as exemplified by more recefit' appomtments~ to the ~hole-time senior administrative posts. For what reason I am entirely at a loss to. understand, as if there is ~ n e s~fvice to/rr~y mihd which is more important to the country at the present time and which shows better value for money spent it is maternity and child welfare work; and yet, things being equal in other respects, the tuberculosis officer gets the pull almost ever), time. If the value o.f results counts for anything the tuberculosis service certainly has not the first claim as its members admit that its results are discouraging. T h e r e is no one -
~.
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16
PUBLIC HEALTH.
w h o has experience of b a c t e r i o l o g y in a public health d e p a r t m e n t w h o does not know that they are not g e t t i n g to the root of the trouble. It is c o m m o n k n o w l e d g e to all who d o the work how great a n u m b e r of specimens sent in for the first time are s w a r m i n g with tubercle bacilli. As a public health administrator there is no question in m y mind of the c o m p a r a t i v e i m p o r t a n c e of the two kinds of work. T h e r e is a n o t h e r idea which seems fixed in so m a n y people's minds, bo.th municipal and a p p a r e n t l y State, that the single women who. constitute a large p r o p o r t i o n of the maternity and child welfare officers of the present d a y are specially qualified b y reason of their sex to deal with ante-natal work a n d to deal with the m o t h e r s and the p r o b l e m s which arise in married life. W h i l s t not e x p r e s s i n g a n y political opinion as to the e m p l o y m e n t of married women, there is surely no branch of work in which t h e e m p l o y m e n t of married w o m e n - - a s c o m p a r e d with the single women - - i s of such e n o r m o u s a d v a n t a g e . T h e r e is no d e n y i n g the fact that married life is to. a large extent a closed book to the u n m a r r i e d , as closed as f r e e m a s o n r y to those who do not b e l o n g to the craft, a n d the fact that the officer is still single m e a n s that she has not yet experienced that most wonderful t h i n g which is the basis of all married l i f e - the mutual love of a m a n a n d w o m a n . T h e u n m a r r i e d w o m a n c a n n o t enter into and discuss the details of married life in the same way as a married w o m a n or married man can. T h e y are m u c h in the position of T o m l i n s o n , as described b y K i p l i n g , who, after he had v a i n l y a t t e m p t e d to gain admission to Hell, a n d h a v i n g been refused, applied at the gates of H e a v e n , a n d was there dismissed with utter scorn on the g r o u n d of inadequate knowledge, with the p a r t i n g words : " A n d the G o d that you took from a printed book be with you, T o m l i n s o n . " : their k n o w l e d g e is incomplete. At present in m a n y o,f the larger districts the work is cut up into special d e p a r t m e n t s with a t e n d e n c y to a p p o i n t an officer to do school work and an officer to do m a t e r n i t y and child welfare work, and in the discussions which have taken place recently there is that drawback which so often arises, viz., that the individuals discussing the subjecc will o n l y discuss it in terms of the office they hold and not in the larger sense o f the c o u n t r y at large. In large centres like L o n d o n , B i r m i n g h a m and M a n c h e s t e r things are quite different from
OCTOBERj
the smaller areas existing, and areas which are arising, which form the great majority of administrative units. W i s e l y u n d e r the advice of the M i n i s t r y of I I e a l t h the union of districts is b e i n g b r o u g h t about to create, whole-time single unit areas. T h e r e is a tend e n c y when these grow, and extra assistance is required, as far as one can see, in the first place to get the extra assistance required for m a t e r n i t y and child welfare work on a parttime basis. T h e r e is also a t e n d e n c y in some of the larger towns fo.r some of these part-time maternity and child welfare officers to attempt to specialise entirely in infant feeding. \Vhilst specialisation is alright up to a certain point there is, I think, infinite h a r m both to the cause and to the individual in m a k i n g that specialisation too narrow. T h e r e is a great d a n g e r to m y mind in specialising in work in which a large n u m b e r of the cases seen require practically no medical t r e a t m e n t or advice, as in child welfare work and School medical inspection. In ordinary specialisation at a hospital the cases which present themselves fo.r treatment and observation are in e v e r y case d e p a r t u r e s from the normal and, from that point of view, full of interest. F u r t h e r , if y o u take the people who are specialising in c h i l d r e n ' s work, whose n a m e s in their v a r i o u s districts c a r r y the weight o.f authority, you will find that all of them have the wider interests of a c h i l d r e n ' s hospital with all the manifestations of c h i l d r e n ' s disease and its treatment, or of some other h.ospital. T h e n a r r o w specialisation such as is offered by infant welfare work and similar kinds of work t e n d s to p r o d u c e in course of time a slackness of m i n d a n d an a u t o m a t i s m which is not f o u n d where the interests are wider. As far as infant welfare work is concerned, to those d e v o t i n g themselves ~to that class o.f work there would a p p e a r to be comparatively l i t t l e . f u t u r e . C o m i n g now to the more i m p o r t a n t questio.n of the clinic, one of the administrative difficulties is the n u m b e r of patients that should be seen by the medical officer, m y own feeling b e i n g that a b o u t t w e n t y is the n u m b e r which gives the best result. S p e a k i n g to a medical officer of a clinic some while a g o I received the following reply : " A f t e r twenty m y enthusiasm dies r a p i d l y . " M y own experience coincides entirely with that statement. L a r g e n u m b e r s tend to spoil the work by d i m i n i s h i n g the time which should be given to parents, and the parents in turn feel that if the work is of
~92s.
PUBLIC HEALTH.
such little impo.rtance that it has to be scrambled through, they are not going to pay the same attention to the advice given as if it appears to be of such importance to the local authority that adequate premises and staff are provided and sufficient time is allowed for carrying" out the work. It is difficult to assess the average attendances which should produce an average of about twenty to be seen by the medical officer, and it would be interesting" to. find what are the opinions of the various officers carrying out the work with regard to that. T her e is another administrative diffÉculty which varies in different districts; this is as to whom shall the attendance at the clinics be limited. In some districts a wage limit is apparently fixed with the idea that it is only the very poor who want advice with regard to br i ngi ng up their children. As far as my experience goes, ignorance with regard to the u p b r i n g i n g . o f children is not the prerogative of any class from the highest to the lowest. T h e r e is a very definite difficulty at present in many districts around L o n d o n with regard to. t h e influx of a new population whose finances would on the surface appear to be such that they can easily afford medical attention by their private doctor. A large proportion of these are buying their houses under assisted schemes and have little or no margin, and even if there is a margin, that m a r g i n is rapidly diminished to vanishing point when there is any continued sickness, which means substantial doctor's bills. It is those of us who are actually doing maternity and child welfare work and who know the conditions under which the people live, who realise that the majority of them cannot p a y for much medical attention. W h a t usually happens, then, is that if they -are refused at the clinic the child's little ailments are allowed 63 go. without skilled attenti0n q r. it'dvice. Such advice as !s~..given is general!y of the wrong kind, particularly .if" given by either of the mothers-in-law, and it is not until the chitdoh~s qSdety.,dep~rted~;#rom the normal and is really ill that they feel that they must s p e n d the necessary amount on medical advice. I am now g e t t i n g into my clinic a class Which I never had befo.re, partly I think owing to. financial circumstanges, partly I find due to the realisation that they get advice as a rule in the maternity and child welfare clinic which is not available elsewhere.
17
H a v i n g been in general practice for eight years before coming into public health, I can speak from experience with respect to the general practitio~ner. It is not. the fault of the older ones that they received no teaching whatever with regard to infant welfare work and infant feeding. Tile relative importance which was attached to this large subject has to be gauged by the fact that it is onl y within quite recent years that a single question on child welfare and infant feeding or even pediatrics as such was considered necessary in the qualifying examination o.f the medical student. T h e r e is, as a result, amongst many of the older practitioners a want of appreciation as to what is being done and can be done in a n infant welfare clinic. In some cases there is ,definite hostility, which I think is a pity, but I think that there may be grounds for some of this in the way that some clinics undertake treatmenl. Some general practitio.ners feel that work is being taken out of their hands, and the sphere of usefulness of the general practitioner is being narrowed by the work carried out in the municipal clinics. I, perso.nally, should say that instead of that, the clinics both maternity and infant welfare and school are responsible for sending to the the general practitioner cases which he would never get otherwise. [n order to keep the goodwill of the practitioners of my own district, I do not undertake any treatrnent whatever except that strictly limited to dietetic corrections, and the simplest possible matters bordering .on them, and this I believe is the general policy. Another difficulty that clinics have to. face is a want o.f consideration on the part of physicians in charge of some of the infant welfare departments of the larger hospitals for the maternity and child welfare officer working in the clinics. Many of these medical officers-are,persons of wide experience in this particular branch, o.f 'work, and it is galling t o a degree to send a case to a hospital fo.r spjne r.eason other than dietetic,, when the child is being k e p t on a certain kind of diet for some satisfactory reason, to have t he child sent round to the hospital infant welfare department where the physician in charge orders an entirely different method of feeding, and later the medical officer at the clinic gets a letter from the hospital authorities to the effect that tt~e child has been placed under the control of Dr. X, who has ordered the
J8
PUBLIC
child such and such a diet and would the medical officer at the clinic see that it is provided. T h e medical officer in return for such want of consideration will take very good care that no patient is ever advised to attend that hospital again. T h e r e is, unforttmately, a want of co-o.rdination between m a t e r n i t y and child welfare work as carried on b y the municipal authorities and the v o l u n t a r y hospitals on the one hand and the p o o r law authorities on the other. In the big towns there is the difficulty that the c h i l d r e n ' s hospitals a r e so far from the homes o.f the people, and in the smaller towns so. far from the h o m e in the c o u n t r y areas, a n d here a g a i n there is the e x t r a o r d i n a r y want of u n d e r s t a n d i n g a m o n g s t some of the hospital p h y s i c i a n s and a m o n g s t the j u n i o r officers as to the financial capabilities of the patients wlno come to. them. It is not u n c o m mon, as e v e r y medical officer either to a centre or a school clinic in the greater I . o n d o n area will bear out, fo.r a patient who has been to a hospital to return with the message that Dr. X wants them to go twice a week. We have sent them up for advice; m u c h of the treatment, if not all, could be carried out in connection with the clinic, and what does twice a week mean to these u n f o r t u n a t e parents ? F r o m the outside ring of L o n d o n or even in our provincial towns, c o m i n g in means a substantial expense. T r a i n fares from the outer ring of Lo.ndon m e a n 1/6 if the child goes free, if not, a n o t h e r 9d. In order to get to the hospital for the afternoon out-patients, it means leaving before 11 in the m o r n i n g , g e t t i n g away about 3.,30 to 4 in the afternoon a n d h o m e about 5.30 p . m . or later. As often as not a b a b y has to be taken if the toddler is the p a t i e n t ; this all m e a n s a payment of about 2/3 plus the cost of any food, and a m o t h e r dead beat b y the end of the day. I n v a r i a b l y when I ask a m o t h e r w h y she has not attended the hospital again, the reply is : " It's no use, doctor, I simply c a n ' t affo.rd i t . " At times I find a m o t h e r g o i n g short in order to get the m o n e y for the fares. O n e of m y most decent little mothers d u r i n g a conversation s a i d : " Y o u know, doctor, before the war I made a point of s a v i n g 3d. every w e e k . " H o w much is c o n v e y e d in that ; insolvency plus ~3d. equals solvency ? T h e r e must be provided, b y some m e a n s or other, greater facilities for s e n d i n g cases for further treatment and advice in the neighb o u r h o o d of the clinics. For instance, in
HEALTH.
OCTOBER,
L o n d o n there is a definite s h o r t a g e of children's hospitals in the outer ring. I say c h i l d r e n ' s hospitals advisedly because, speaking from m y o,wn experience in hospital work I a m convinced that the best c h i l d r e n ' s work is done in a hospital devoted entirely to children. T h e r e is, if one m a y say so, a h i g h e r standard of k n o w l e d g e and a different atmosphere of u n d e r s t a n d i n g of the clnild botti b y the medical staff a n d nurses, in hospitals devoted entirely to. children, in contrast to the hospitals where the c h i l d r e n ' s section is o n l y a small p r o p o r t i o n of the work. A problem which is often b e i n g b r o u g h t up is the question of the financial status of people who should be supplied with the dried milks and such like things at the clinics at the reduced prices at which the clinics a r e a b l e to sell t h e m as c o m p a r e d with the prices c h a r g e d in the shops. Certain proprietors of infant foods have no.t been above c o m p l a i n i n g to the Go.vernment d e p a r t m e n t s that their sales are seriously prejudiced b y the s u p p l y of dried milks and other t h i n g s at costs below which their p r o d u c t s are retailed in the shops. W e are pestered b y the representatives of this and tlnat particular article, w h o claim for their preparation qualities possessed by no other. E v e r y public c o n v e y a n c e flaunts the claims of some patent food. It is a c c o m p a n i e d by alluring pictures of some comely maid who is administering to the ailing, or illustrations of some child who would have do.ne equally well on some other food or even on its own m o t h e r ' s lnilk. P e r s o n a l l y , i am v e r y loath to utilise widely advertised articles of diet. It would be a great i m p r o v e m e n t if, b y some m e a n s or other, local authorities would combine to m a n u f a c t u r e s t a n d a r d milks for use in their clinics. H o w m a n y people realise what it means to feed a child on these p r e p a r a t i o n s at the prices which are c h a r g e d for them ? A s~mrt-.'dme a g o a new m o t h e r came in who. had been put on one of these p r e p a r a t i o n s b y ' h e r general practitioner, a n d had o n l y come to the clinic because she said she s i m p l y could not afford to carry on a n y longer. S h e was now getting" into the fourth tin a week, and the cost would then be 10/- per week. If people would only think for a m i n u t e that that represents the g r e a t e r - p a r t of the house rent for the entire family, it would give them some sense of proportion when dealing with these things. O n l y c o m p a r a t i v e l y recently at a clinic in ,the greater L o n d o n area a m o t h e r came in and asked the
~928.
PUBLIC
medical officer for a certain widely advertised article of infant food, and was told that they did not supply it. After she had left the traveller for that particular article of food asked to see the medical officer, and demanded to know why their food was n o t stocked; the whole thing obviously being a put-up job. T h e n there is the question of milk supply. W e who use large quantities of dried milk are railed at b y the clean milk purist on the grounds that we make a supply of dirty milk easier by not encouraging the demand for clean wet milk. I think I am right in saying that the general experience is not such as to encourage the supply of wet milk fo.r infant feeding. T h e poorer mothers cantmt afford the higher priced grade " A " or certified milk, and even if the milk is pasteurised there is no question fis to the superiority of the dried milk from a safety point o.f view. Personally, I am unrepentant, tt is the i:arest thing for me to use wet milk if I have to feed artificially. Another difficulty is that of getting in touch with the ante-natal cases. T h e reasons are, I think, partly that the women are not yet educated up to attending the ante-natal clinic, and further I am convinced that the presence of municipal midwives is a very definite bar to their attendance, due to the fact that the midwives of the district have a f e e l i n g - - a n d in some cases not without cause - - t h a t if their patients attend the ante-natal clinic they are likely to have pressed upon them the value of the municipal midwife's attentions, and thus lose their patients. I believe that where there is difficulty with adequate midwifery services the best results are obtained by subsidising competent midwives so that they c a n make a living rather than attempting to appoint a municipal midwife. Difficulty also arises where there is a municipal maternity home as to the class.of pat!ent "~ho shall be' 'admitted. It should be, ifl I.n) opinion, a fundamental point that no patient should be ~dmittedo wt3o2-ha~, no~atten~t~ed an ~nte-natal ctinic or can produce d derf{i~cate fro.m her medical practitioner that she h a s been examined a t least twice within the last four months, thus ensuring that ante-natal supervision which means so much towards the warding off of diNculties later on. ~:hen again there is the difficulty of admitting the*emergencies that have arisen during confinment outside. My own opinion is that these cases should be resolutely refused, and
HEALTH.
19
should be sent elsewhere, as it is n o t right that a mother who goes into the municipal maternity home postulating a safe confinement should be exposed to. the risk of infection brought in by someone who has not taken the same precaution as she has to" ensure a satisfactory confinement. Another difficulty is the staff necessary to run satisfactorily a well-attended clinic. T h e maternity a n d child welfare work is the only branch of public health activity where vo.luntary workers are advocated as members of the staff. T h e Ministry assess the necessary health visito.rs at 1 to every 300 births. T h e r e must, however, be wide variations in the demand owing to the differences in the residential character of tile area e m p l o y i n g them. T h e voluntary worker can be and very often is an invaluable adjunct to tile clinic, provided that they are content to do the work allotted lo them witho.ut attempting to interfere with the professional side of the work. Voluntary workers m a y be divided into two classes of work. T h e leisured class and those who do not belong to the leisured class. T h e r e are those who really understand the responsibilities attached to the work. T h e r e are others, however, who do not, and who allow their social calls to interfere with the responsibilities they have assumed. T h e r e are still many of these people who do not really understand the conditions under which the poor live. W i t h i n the last month a case was brought to m y knowledge by one of the voluntary workers in a very poor district, where the wellmeaning voluntary committee r u n n i n g the centre, of which she was a member, suggested that a demonstration on washing and bathing the baby should be given to the mothers on a Friday, and either ad. or 6d. be charged for admission. T h i n g s begarr to get quite uncomfortable, when the member who visited the poor ~and really understood their needs pointed out the f.utit~ty o f the suggestion, first on the g r o u n d of the fee for admidsio.n and secondly on the .ground that Friday was pay ~fay, "and tla/it .hntit l~riday evening" there was no money in the house. It was then suggested that the demonstration should t a k e place on a Monday, and things got more uncomfortable whela the same member, with a knowledge of conditions, pointed out that M o n d a y was washing day. W i t h the non-leisured class I have been singularly fortunate in those who have volunteered for service in m y various clinics, and I record with deep gratitude their
so
PUBLIC
devoted services week in, week out, and in some cases year after y e a r . W i t h respect to the poor law, there is also want of close co-ordination. For instance, recently a m o t h e r was admitted to the local hospital with eclampsia the d a y after her confinement. T h e father made an application for assistance in the matter of food for the children next day. t i e was in great difficulties; one n e i g h b o u r had taken both children d u r i n g the day, but h a v i n g her h a n d s so full she was o n l y able to take one at night, the other b e i n g taken b y a n o t h e r n e i g h b o u r . I pointed out that in the c h i i d r e n ' s interests there was o n l y one t h i n g to do, and that was to get them admitted at once to the local poor law institution. T h i s he a t t e m p t e d to do, but was met with the reply that it was impossible to admit the children unless he went in too. T h e man at the time was out of wo.rk, but surely there is s o m e t h i n g lacking in our m a c h i n e r y which refused to do what is necessary for the children without c o m p e l l i n g the h u s b a n d to enter the workhouse. T h e r e s h o u l d also., I think, be closer co-ordination between the p o o r law and the m a t e r n i t y and child welfare centres, so that if it is recognised that the centres are the places where special care can be taken of children, parents in receipt of poor law relief could be referred to the clinics, and an a r r a n g e m e n t made w h e r e b y the cost of the food for their children was paid b y the guardians. T h e r e is a n o t h e r difficulty which is constantly c r o p p i n g up, namely, the g i v i n g of s t a n d a r d advice b y means of leaflets. T h i s has been p u t before this G r o u p for consideration and u r g e d b y certain other societies interested in c h i l d r e n ' s work. M y own feeling is that it would be a grievous mistake to standardise advice when so m a n y are getting" the same results b y using" different methods. T h e r e is m u c h more likelih(~od of advice b e i n g followed if it is given by a medical officer than if a palnphlet is simply h a n d e d over and the m o t h e r is told to follow the directions on the printed leaf. W h a t of the future ? Is m a t e r n i t y and child welfare work to stay as it is at p r e s e n t - - a water-tight division in the child's life, or is it to become part of a unified whole, dealing with the child from the cradle till the time it is taken over b y the autho.rities dealing with the I n s u r a n c e Acts ? T h e i m p o r t a n c e which was attached to school medical work in years g o n e b y has now
HEALTH.
OCTOBER~
passed to the pre-school child who is u n d e r the care of the m a t e r n i t y and child welfare centres, and we are more and more realising that the a g e - g r o u p which has to be co,ncentrated on is the one which is now missing the necessary medical supervision v e r y largely, n a m e l y the child from 2 to 5. Sir G e o r g e N e w m a n is c o n s t a n t l y r e f e r r i n g to the p e r c e n t a g e of entrants into our schools with defects which m i g h t have been remedied some considerable time before c o m m e n c i n g school. It is difficult at present to say how that ageg r o u p can be dealt with except on the lines of persuasion, i t will be, I think, for some time mainly b y the activities of tactful health visitors that this a g e - g r o u p will come u n d e r medical supervision, b u t in order to do our d u t y b y them we must have all the necessary facilities for dealing" with m i n o r a i l m e n t s - - e a r troubles, eye troubles a n d such like, in addition to the facilities which we now possess for o b t a i n i n g dental t r e a t m e n t . H a v i n g got those it is illogical to expect an entirely separate m a c h i n e r y to be dealing with children below 5 and over 5, possibly from the same house, suffering from the defects which the clinics are able to deal with. M y own feeling is that, speaking of the c o u n t r y generally, the best results are g o i n g to be obtained not b y too great specialisation, but b y the unification of maternity and child welfare work with the o thei- public health services, both as r e g a r d s the medical p e r s o n n e l a n d the n u r s i n g personnel. As an illustration an able health visitor, who had experienced both classes of work in her own district, said to me quite, recently : " W h e n I was g o i n g into a house whilst d o i n g both kinds of work, I knew all the family, went as a friend of the f a m i l y a n d had much greater ease in g e t t i n g t h i n g s remedied than I have now w h e n I g o in s i m p l y as a school nurse a n d am a complete s t r a n g e r to a large n u m b e r o f the f a m i l y . " In most o f , the c o u n t r y areas the medical, officers will be c a r r y i n g out all the duties of the s~ho.ol medical service a n d maternity., a n d child welfare work in their own allotted area. T h e r e should be this closer Co-ordination referred to with the local hospitals o.n the one hand, who are in a position to. give the skilled attention or advice required, a n d the poor law institutio.n on the other, a n d we m a y possibly see in the revisio.n of the poo.r law services some definite advances in that direction. W i t h r e g a r d to the .staff in the clinics there will p r o b a b l y be for m a n y years to come a
t928.
21
P U B L ~ HEALTH.
supply of helpers which we tind at present so necessary to eke o.ut the professional assistance. There is some compelling force about the infant which draws into the clinics a sufficient number of helpers who are not in the least attracted towards work amongst adults or even older children. I think, too, as we find persons from a higher social and financial status making use of the State-supplied schools there will be, if the maternity clinics keep up the necessary standard of work, a definite inclination on the part of some of these people to utilise the services of the clinics staffed by the officers of the local authority. Nor do I see quite how it is going to be logical to exclude these people so long as
The
they are at liberty to make free use of the State-supplied schools. There will probably, therefore, be some move on the part of the general practitioner to establish some sort of boundary line in the same way as has been established in the Ihsurance ~cts, but it is not likely, in my opinion, to carry a n y t h i n g like the same weight as it might do so long as the clinics are carried on as the majority are at present. As I pointed out before, they do not take work from the general prac.titioners, but actually put wo.rk into their hands, as in the majority of clinics, as soon as ever a child can be called ill, it is sent post haste to its own medical adviser or to the poor law o.r hospital as the case may be.
Private Practitioner the Pflblic Health.
and
By S. Fox LINTON, M.Sc., M.D., D.P.H., Medical Officer of Health, Scarborough.
The recognition of the importance of the relation between the private practitioner of medicine and public health is general, and the suggestions of Dr. Fox Linton, contained in his Presidential Address to the Yorkshire Branch, on February 24th, 1928, as to how it may be ensured and strengthened, are worthy of serious consideration. ET us consider a problem which is assuming L greater and greater prominence as the importance of personal hygiene comes to be more and more recognised as equal to that of environmental hygiene. By what means can private practitioners best be enabled to take their proper share in the preventive medicine of the future, associating themselves more closely:with official preventive agencies and carrying into the homes of their patients the ideal of prevention rather than of cure ? Nowhere yef has a complete scheme been devised for basing the whole fabric of personal and domestic hygiene on its proper foundation--the medical practitioner, but some" attempts. have" been ma.de. In Australia, for example, some initial steps h'ave been taken with tl~e object of lncFtgdmg the general practitioner as a working element in the public health system. Since 1921, the Commonwealth • Director-General of Health has made a practice of attending the bi-annual meetings of the British Medical Association in Ausf;alia, on each occasion taking the opportunity to 'have an unofficial talk with representatives of the Association. This has resulted in a nmch closer association between the
official departments and the controlling body of the medical profession, and a keener consideration by the profession of its individual responsibility in matters of public health administration and possible reform. The British Medical Association in Australia has accordingly drawn up a statement for the consideration of the whole profession of which the following is a short outline: ..... After emphasising the desirability of linking up the general practitioner into active participation in the administrative scheme, it suggests .that his preventive "work, in addition to notification of births, still-births, miscarriagds, ffeaths, infectious di~seases and cases of mineral and org~inic (alcoholic, etc.) poisoning, should include the ordering of prescribed rh~thods of. disinfection in infectious cases, the taking of swabs and other specimens for the detection of carriers, the examination of school children in particular districts (i.e., in country schools), and other duties as prescribed from time to time by regulations or as requested by the health officer. The practitioner is to receive fees for all such work. The Director-General of the Commonwealth, giving evidence before a Royal Commission