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The medical officer—Prospect and introspect
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t'UBLIC HEALTtt, February, 1947 has become reconciled to the strangeness of c o u n t y councils being considered as h e a l t h authorities, e d u c a t i o n m a y have progressed sufficJently for those in a u t h o r i t y to have learned the value of t h e smaller authorities. T h e Local G o v e r n m e n t C o m mission m a y b y t h e n have come to t h e conclusion " t h a t M r . Bevan m i g h t indeed have got a m o r e m a n a g e a b l e t e a m ff h e h a d disregarded the p r e s e n t legal status of local authorities a n d c h o s e n t h e 40 largest counties, t h e 60 largest c o u n t y b o r o u g h s a n d t h e 50 largest b o r o u g h s or u r b a n districts to b e t h e local health authormes." [The Times leading article, July 27th, 1946.] DISCUSSION
Dr. J. A. Charles (Ministry of Health), after complimenting Dr. Caryl Thomas on the excellence of his address, outlined the reasons which actuated the Government in the promotion of the Bill and referred to the position of Medical Officers of Health. He did not think Medical Officers of County and County Boroughs need worry. They would probably lose the Tuberculosis and Hospital Services, but there would be~ ample opportunity for men o[ imagination to find a satisfactory field of work. The removal of hospitals from the County Borough man was not going to be a great loss. He rather felt that in the future the M.O.H. must be concerned with social medicine, epidemiology, and honsing, and suggested there was a considerable field ef activity in the latter. He felt quite certain that better results would come if the Medical Officer was looking after various aspects of housing. He mentioned that in the United States a large amount of work had been done in increasing home safety. He instanced that more children died in New York from domestic accidents than in the streets. There were various danger points in housing, i.e., electric fittings, dangerous stairs, etc. All these could be looked into. He thought public opinion would demand that something should be done to put industrial welfare on a better basis. This was a field to which Medical Officers of Health could turn their minds. There was also the question of the aged and partially infirm people. Medical Officers of Health might be able to suggest how existing arrangements could be improved. Iil conclusion, however, he thought that short of delegation by County Councils there was very little to rally the spirits of the non-County man. Dr. Townsend (M.O.H., Buckinghamshire) said it seemed to him that in the future we should have to take up a different line and be more concerned with the social side. He considered that Medical Officers of Health should be co-ordinators rather than administrators. He tllought we were coming to the parting of the ways and wondered if Medical Officers of Health were not now in a position to hand over the administrativ~ machine. In this way it would be possible to have more time to get back to essential things. He thought Medical Officers of Health would be well advised to concern themselves with the social side of the work and hand over the administration to a trained layman. Dr. A. Anderson (M.O.H., Heston and Isleworth M.B.) said the position of the M.O.H. of the County and County Boroughs was of course assured, and he (lid not think they should mind losing the hospital service, etc. There were plenty of other matters to which attention could be directed and he instanced the following up of cases in the home after their discharge from hospitals. The position of the district M.O.H. was entirely different. If he was a man of initiative there was going to be very little scope for him. It was all very well to say that he would be able to look after housing, rats and mice, etc., but where was that going to lead him ? There would be no clinical work or administration. There might be a few senior jobs on the county council staff but the outltrok generally could only be described as very black. A very interesting discussion followed in which Drs. Garrow, Starkey, Brown and others took parr. Col. D. Gordon Cheyne, O.B.E., M.C., R.A.M.C. (Dep. Dir. of Hygiene, Southern Command), has been made an officer of the Legion of Merit, U.S.A., and a Brother of the Order of St. John of Jerusalem. Mr. S. Brabington-Perry, L.I).S., mc.s. (ENG.), D.E.C.D.S. (PARIS), nt 47, West Street, Boston, Lines, has been nominated by the Socirtd Francaise d'Hygirne Scolaire et Universitaire, of Paris, to be their corresponding member in this country. He requests comnmnications on medical, dental and educational subjects which nfight be of interest for nlention in the Soci~tCs Bulletin of which the first number is due shortly. He will also be pleased to assist with information on the International Congress organised by the Socirt6 to be held in Paris from June 25th to 29th, 1947 (see I'FBI.i(: Ih.;~l'lll, Novcmher, p. 46).
THE MEDICAL OFFICER--PROSPECT AND INTROSPECT* By E. D. IRVINE, M.D.,.D.P.H.,
Medical Officer of Health, County Borough of Dewsbury T h e p u b l i c h e a l t h service m u s t feel some anxiety for the future. O n t h e one h a n d , the diagnostic a n d curative medical services are to be r e m o v e d f r o m the direction of local a u t h o r i ties a n d transferred to t h a t of regional boards, agents of the M i n i s t r y of Health. O n t h e other, t h e r e are political opinions w h i c h would reduce the status of w h o l e - t i m e public h e a l t h medical officers to t h a t of skilled technicians, mere executive i n s t r u m e n t s of State or local policy ; a n d others w h i c h would depress t h e i r incomes accordingly. T h e views of clinical consultants have b e e n given perhaps an u n d u e p r o m i n e n c e as c o m p a r e d w i t h the views of those whose s t u d y has been t h e a d m i n i s t r a t i o n a n d practice of public h e a l t h ; we can say this w i t h o u t disparaging the hospital consultants or general practitioners. M a n y in o u r b r a n c h of m e d i c i n e would claim t h a t their reasoned conclusions are as valuable as is t h e advice of the consultant for his particular patients--~vith the difference t h a t it is h a r d e r to p e r s u a d e those w i t h political power to e n s u r e the application of the c h o s e n r e m e d y t h a n it is to p e r s u a d e the m a n w h o has paid his c o n s u l t a n t ' s fee to accept the advice given. M a n y of o u r colleagues in t h e i r clinical fields (school health, m e n t a l deficiency, child welfare, a n d tuberculosis, to cite examples) are c o n t r i b u t i n g as m u c h to p u b l i c welfare as recognised clinical c o n s u l t a n t s . T h e s e c o n t e n t i o n s s h o u l d b e r e m e m b e r e d w h e n s h a p i n g the things to come.
The Steady Progress of Centralisation T h e transference of hospital a n d allied powers f r o m local authorities to the M i n i s t r y is b u t a f u r t h e r stage in the steady progress of centralisation. F o r years t h e r e has b e e n a drag f r o m local to regional g o v e r n m e n t ; first, in those services d e m a n d i n g large scale financial resources a n d n o w in all public h e a l t h services, e v e n t h o u g h they affect the lives of the people in t h e i r o w n h o m e s a n d in a m o s t personal way. M a n y medical officers (usually from large authorities) s u p p o r t these trends, m a n y (usually f r o m small places) oppose t h e m . Politicians, too, are divided. I t has to b e a d m i t t e d t h a t m a n y small authorities have failed to do t h e i r work. B u t b o t h the M i n i s t r y a n d c o u n t y councils have equally failed in n o t exercising t h e i r default powers in the P u b l i c H e a l t h Acts (Sections 3 2 1 , 3 2 2 o f t h e 1936 Act). Again, s o m e small authorities have b e e n h a m p e r e d b y i n a d e q u a t e financial resources in the absence of subsidisation f r o m national funds. W h e r e the a u t h o r i t y employs w h o l e - t i m e medical officers of h e a l t h the work has at any rate reached a reasonable standard. T h e Local G o v e r n m e n t Acts, 1929 a n d 1933, b y inference recognise this (section 59 in the former, a n d sections 111/112 in the latter). T h e fact is t h a t t h e work of an authority is as good as its officers. T h e transference of functions f r o m smaller to larger authorities (which if repeated often e n o u g h changes the s t r u c t u r e of local g o v e r n m e n t ) is n o t easily justified, especially w h e n the functions affect closely t h e personal lives arid h a b i t s of t h e people. A d m i n i s t r a t i o n at the centre reduces contacts between the authority, its officers a n d the p e o p l e ; rate d e t e r m i n a t i o n at the centre does n o t increase t h e a m o u n t of m o n e y collected n o r does it decrease the a m o u n t of m o n e y necessary. C h a n g e s w h i c h steadily reduce the n u m b e r of chief officerships m u s t seriously a n d adversely affect r e c r u i t m e n t . W e ought, nevertheless, to be grateful for t h e generous outlook of certain county councils a n d t h e i r c o u n t y medical officers (notably the W e s t Riding, L a n c a s h i r e a n d Surrey, a n d no d o u b t others) w h i c h have a d o p t e d schemes of divisional medical administration, giving so far as the law permits local influence a n d a u t h o r i t y to medical officers of h e a l t h w i t h i n the c o u n t y framework. T h e s e schemes will be u n d o u b t e d l y to the great advantage of all c o n c e r n e d a n d especially to the people. B u t t h e i r very w i s d o m is a n a r g u m e n t against the larger u n i t of a d m i n i s Abstract of Presidential Address to the Yorkshire Branch of the Society of M.O.H., October 26th, 1946.
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tration. There is no ideal unit for all local government purposes ; but a nearly all-purpose unit with both urban and rural characters of resources large enough to be economic and of area small enough to secure local interest and pride, and to maintain contact between the authority, staff and people, is surely the ideal solution. Maintaining Local Unity I conceive it to be one of the main functions of the M.O.H. to secure unity of purpose between the authority and the people in the local sphere. A uniform standard may not be desirable; what is necessary is a minimum standard which all must be encouraged to surpass. Centralisation or regionalisation of the local government service means increasing national control in local affairs ; we must decide for ourselves whether we think that a good thing. Despite the assurance even of Ministers, the signs suggest that we are witnessing the beginning of the end of local government as we have known it. T h e alleged advantages of the two-tier system of local government will, I believe, prove to be an illusion. Obligations and rights cannot be made effective without corresponding power, and with control from above interest at the lower level disappears. For this reason hospitals are right in demanding that their management committees shall have substantial powers. Uniformity imposed from above will stultify progress in hospitals as in the public health service. Nevertheless, local authorities will still be responsible for environmental hygiene and will no doubt attack the problems of social medicine. Our work may be different but not less interesting, less clinical perhaps, more social and still personal. It may develop more into research channels--the ascertainment of defect not only in the individual and his environment but also in the family and the home, and in the community. The care of the potential mother is of profound significance, the problem of population and re-creation of pride in family are of fundamental significance to the race and of immediate importance to the M.O.H. The homeless child and the broken family afford medical problems which we are in the best position to elucidate; the care of the aged has been neglected; the significance of social factors in the causation of many diseases--such as rheumatism, tuberculosis--is not clearly established; the epidemic character of many minor affections, and the domestic epidemic in respiratory and other infections, demand detailed s t u d y ; the meaning of place in family i n psychology, the biological significance of sudden death in child birth, the effect of artificial feeding and prematurity in later life, the balance of work and play in the making of personality are all problems which the public health service should help to solve. I n the more immediately practical sphere we have housing problems, the smoke nuisance, efficiency and nutrition in children and adults, control of intestinal infections, maintenance of pure food supplies and many more. We should not allow anyone to think that the M.O.H. has not a primary interest in food and housing, the two fundamentals of health. In all these matters the public health medical officer has important advisory as well as executive functions, and his contributions will be measured more by his significance in the former rather than in the latter sphere. Here his character and philosophic outlook, no tess than his scientific knowledge, make their vital contribution. We must influence those with political power without becoming avowed semi-professional politicians. The Community and the Individual
Health education remains par excellence an activity of the public health service ; we are undoubtedly in the best position to ensure and maintain an informed opinion on public health. Pressure by the people on their own behalf will secure much needed reform. I n recent years health education has become lopsided. We know the good work the Central Council for Health Educatior/ is doing, but V.D. and sex education have, in my view, taken too prominent a place in national health propaganda, due mainly to an approach to human problems
PUBLIC HEALTH, February, 1947 based solely on science and not informed by philosophy. There is a danger in thinking of man simply as a biologic unit set in an organic community. Making V.D. " j u s t one of the other infectious diseases " and " readily cured " is going too far in simplification. No one would not want to persuade towards early treatment, but our propaganda may even do what it sets out to prevent--increase its incidence. Sex education, too, seems to have passed the bounds of prudence. Instead of encouraging parents to undertake in their own way and time, to enlighten their children, we are indeed encouraging others, especially teachers, to take on this task; to be presented, it is feared, in a shorn of idealism. Too often in the past public health reforms have been initiated on behalf of the industrial effort and not from any primary consideration of individual needs. Progress has been fustified on the score of increased output. That outlook should go. Better health and greater happiness must be the first consideration. We should, as public health officers, always remember the t ~ m a n dignity of the individual. T h e community or society is becoming all important and individual rights are in danger of being submerged. The rights to live, to earn a livelihood, to family integrity, to a just share of the things of the earth, of access to truth are all inalienable. The right to health is implied in the first. There is an obligation on the State to secure to each these natural rights. Often we have to balance the needs of the community and the rights of the individual--secrecy in V.D., and in tuberculosis, the protection of the handicapped child in industry, the putting off work of patients possibly infected (e.g., the food worker affected by diarrhoea) are simple examples where conflicts may arise. The right to marry, the hardships of society on illigetimacy, the provision of meals free only if taken at school provide other instances. The subsidising of one section of the community (e.g., council tenants) of the expense of others equally poor, and the compulsory removal of families from one council house to another are others. Even superannuation poses a problem. If the right to work is absolutely conditional on health, then we have reached a dangerous point. With the increased safeguards of the National Insurance Act, the right to be employed should not be too strictly related to the requisites of a " first-class life." Vocational selection and guidance are much-discussed problems. There is here a grave risk of the imposition on individuals of the view and will of officers of the State and local authority. So long as it is advice and not pressure, no harm is likely, but we must beware always of compulsion. Vocational tests for entrants to the medical profession advocated by this branch some years ago seem to me a dangerous and unwise innovation. Again, accepting that child guidance clinics do good work, we should nevertheless insist that all working with children should have great regard for the personal dignity and integrity of the child. Above all we have the conflict between the parental rights and the rights of the State. In the past public health law and practice have been largely devoted to helping the parents, especially mothers, to rear children at home, and this (with the corollary that the homes must be in houses fit to live in) should be our aim. To mention two matters that are not entirely irrelevant. I have long thought that persons put off work for public health reasons and through no fault of theirs should be compensated ; and secondly, that rebating of council house rents to large and poor families should b e more generous and that the principle might be extended at public expense to other rent-controlled let houses. What of the doctor in all this ? Sir Alfred Webb-Johnson, P.R.C.S., declared (The Times, October 20th, 1946) " that we must ensure that the conditions of service in the national health service allowed intellectual freedom and gave character as much chance as cleverness. " T h e well-equipped clinician must possess the qualities of the artist, of the man of science, and of the humanist, but he must exercise them only in so far as they-subserve the recovery of the individual patient. It is a hard doctrine, but none the less true that this essential function of the doctor--the care of the given patient--might involve the forgoing of exactly
PUBLIC HEALTH, February, 1947
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scientific diagnosis, or the artistic perfecting of an operation or even of the interests of society at large." All this the doctor in private practice must be and do. But too often at present our colleagues in general practice think only of the patient and nothing of the community. T h e public health doctor remembering always that he is a doctor first, and a local government officer second, must be ever aware of his even more difficult task--to reconcile the needs of society with the rights of the individual.
THE ADMINISTRATIVE STRUCTURE OF THE FUTURE PUBLIC HEALTH SERVICE*
By J. S. G. BURNETT, M.D., D.P.H., Medical Officer of Health, Chadderton
Urban District
Much has been said about the future public health service and our new President gave us an admirable survey of the functions that would lie within the sphere of the public health department; but less has been said about the future of the individual medical officer of health, although all of us have been anxious about our own future and that of the younger members of our branch of the profession who would normally be expecting to obtain one of the junior administrative posts. The Meaning of '* Publie Health " Before discussing the future of the officer engaged in the public health service I should like to refer briefly to the nature of the service itself. T o many the term " public health " has meant latterly, in practice, the devoting of up to three-quarters of their working time to planning and administering schemes concerned with the treatment of the sick. T h e development of the hospital services consequent on the Local Government Act 1929 has been a tremendous step forward in the organisation of the medical services of this country, but it was not a public health process. We ourselves have recently pointed out that Mr. Bevan's Bill would be more appropriately named the National Sickness Service Bill. Again, there is a wave of enthusiasm for child health. Insofar as this means the investigation of heredity, the ascertainment of family and school environment and the pyschological and physical response of the child to these factors this truly is part of the public health. When it is interpreted to mean the treatment of defects discovered it is strictly a part of the sickness service. I recognise that under the old departmentalised system there was insufficient scope for the ambitious man or woman and the addition of therapeutic functions tended to ease the restrictive character of the original position. This problem still confronts us. T o me the term public health brings to mind certain historical facts. I am reminded that, as land drainage was effected in England, so malaria ceased to be endemic, and that the increase in population in the 18th century was not the result of an increased birth rate but was due to an increased expectation of life consequent upon an improved standard of living, especially in relation to developments in agriculture. I am reminded that tuberculosis mortality was falling steadily long before the institution of the tuberculosis service and that in the past seven years when the health services of this country were by no means at their highest pitch of efficiency, when men and women were working harder than they had done for years, but also when mass poverty was less than it had ever been before, the health of the nation has stood higher than it has ever done. My conception o f " the public health " is that poverty, overcrowding, bad housing in the home, the school and the factory, a filthy atmosphere, insufficient nutrition and a contaminated food supply, all in association with hereditary and infective factors and an inefficient individual mental stature, are the main factors in the production of ill health and that their elimination or control is the proper function of the public health service. Such a conception embraces preventive measures against the
* Paper to the North-Western Branch, Preston, November 8th, 1946.
occurrence of tuberculosis, rheumatism, peptic ulcer, deficiency diseases, bronchitis, industrial diseases and the infectious diseases, to mention only some of the present-day problems ; but not the treatment of established disease. Such a conception envisages the family as the focal point for investigation and for the application of remedial measures rather than the individual whether it be the infant, the school child, the mother or the aged. The National Sanitary Minimum Sir George Newman, in his " T h e Building of a Nation's Health," referring to the recommendations of the Royal Sanitary Commission of 1869, writes : - " T h e Commission's summary of the national sanitary minimum o f ' what is necessary for eivilised social life ' i n e v e r y l o c a l i t y is the grand inventory of that period : - I. T h e supply of wholesome and sufficient water for drinking and washing. II. T h e prevention of the pollution of water. III. T h e pr~.vision of sewerage and utilisation of sewage. IV. T h e regulation of streets, highways and new buildings. V. T h e healthiness of dwellings. VI. T h e removal of nuisances and refuse, and consumption of smoke. VII. T h e inspection of food. V I I I . T h e suppression of causes of diseases, and regulations in case of epidemics. IX. T h e provision for the burial of the dead without injury to the living. X. T h e regulation of markets, etc., public lighting of towns. XI. T h e registration of death and sickness." Moreover Newman states earlier that " speaking broadly, the Commission of 1843 found the existence of a serious national evil of insanitation and ill health, and recommended legislative remedy, whereas the 1869 Commission found that the remedy had proved ineffective, and recommended that " the present fragmentary and confused sanitary legislation should be consolidated." In other words the national sanitary minimum detailed above was recognised in 1843. Has the national sanitary minimum in every locality been achieved in 1946 ? The Structure of the Public Health Service U p to the outbreak of war in 1939 although the statutory duties of a medical officer of health were laid down by regulation, almost all whole-time holders of the office were in varying degree responsible for other work recognised to lie in the sphere of public health ranging from duties relating to the school medical service, to a complete immersion in hospital organisation and other measures related to the treatment of sickness. In the near future this will be changed and there will be two grades of officer, one whose duties are limited to his statutory responsibilities and a second whose duties will include the administration of the school health service and those other duties relating principally to child welfare and domiciliary disability outlined in Part I I I of the National Health Service Act. T h e anomalous feature of this fission is that it is based not on present-day populations, geographical considerations or efficiency of present services but on the dividing line of major or lesser authority established by the Local Government Act, 1888. A position has been created whereby the medical officer of health of a municipal borough such as Luton, with a population of 105,000 and a rateable value of £770,000, will come within the former grade of officer, wl~ilst his colleague of Smethwick, where there is a population of 74,000 and a rateable value of £420,000, will lie within the latter ,category, despite the fact that the former area dominates the surrounding countryside whilst the latter forms part of a congested urban sprawl. I make no comment on the position of the Urban District of Harrow, with a population of 211,550 and a rateable value of over £2,000,000, and the County Council of Rutland, with its population of 17,000 and its rateable value of £113,000. T h e pronouncements of more than one Minister of the Crown indicate that the Government does not look on such a position
t'UBLIC HEALTtt, February, 1947 has become reconciled to the strangeness of c o u n t y councils being considered as h e a l t h authorities, e d u c a t i o n m a y have progressed sufficJently for those in a u t h o r i t y to have learned the value of t h e smaller authorities. T h e Local G o v e r n m e n t C o m mission m a y b y t h e n have come to t h e conclusion " t h a t M r . Bevan m i g h t indeed have got a m o r e m a n a g e a b l e t e a m ff h e h a d disregarded the p r e s e n t legal status of local authorities a n d c h o s e n t h e 40 largest counties, t h e 60 largest c o u n t y b o r o u g h s a n d t h e 50 largest b o r o u g h s or u r b a n districts to b e t h e local health authormes." [The Times leading article, July 27th, 1946.] DISCUSSION
Dr. J. A. Charles (Ministry of Health), after complimenting Dr. Caryl Thomas on the excellence of his address, outlined the reasons which actuated the Government in the promotion of the Bill and referred to the position of Medical Officers of Health. He did not think Medical Officers of County and County Boroughs need worry. They would probably lose the Tuberculosis and Hospital Services, but there would be~ ample opportunity for men o[ imagination to find a satisfactory field of work. The removal of hospitals from the County Borough man was not going to be a great loss. He rather felt that in the future the M.O.H. must be concerned with social medicine, epidemiology, and honsing, and suggested there was a considerable field ef activity in the latter. He felt quite certain that better results would come if the Medical Officer was looking after various aspects of housing. He mentioned that in the United States a large amount of work had been done in increasing home safety. He instanced that more children died in New York from domestic accidents than in the streets. There were various danger points in housing, i.e., electric fittings, dangerous stairs, etc. All these could be looked into. He thought public opinion would demand that something should be done to put industrial welfare on a better basis. This was a field to which Medical Officers of Health could turn their minds. There was also the question of the aged and partially infirm people. Medical Officers of Health might be able to suggest how existing arrangements could be improved. Iil conclusion, however, he thought that short of delegation by County Councils there was very little to rally the spirits of the non-County man. Dr. Townsend (M.O.H., Buckinghamshire) said it seemed to him that in the future we should have to take up a different line and be more concerned with the social side. He considered that Medical Officers of Health should be co-ordinators rather than administrators. He tllought we were coming to the parting of the ways and wondered if Medical Officers of Health were not now in a position to hand over the administrativ~ machine. In this way it would be possible to have more time to get back to essential things. He thought Medical Officers of Health would be well advised to concern themselves with the social side of the work and hand over the administration to a trained layman. Dr. A. Anderson (M.O.H., Heston and Isleworth M.B.) said the position of the M.O.H. of the County and County Boroughs was of course assured, and he (lid not think they should mind losing the hospital service, etc. There were plenty of other matters to which attention could be directed and he instanced the following up of cases in the home after their discharge from hospitals. The position of the district M.O.H. was entirely different. If he was a man of initiative there was going to be very little scope for him. It was all very well to say that he would be able to look after housing, rats and mice, etc., but where was that going to lead him ? There would be no clinical work or administration. There might be a few senior jobs on the county council staff but the outltrok generally could only be described as very black. A very interesting discussion followed in which Drs. Garrow, Starkey, Brown and others took parr. Col. D. Gordon Cheyne, O.B.E., M.C., R.A.M.C. (Dep. Dir. of Hygiene, Southern Command), has been made an officer of the Legion of Merit, U.S.A., and a Brother of the Order of St. John of Jerusalem. Mr. S. Brabington-Perry, L.I).S., mc.s. (ENG.), D.E.C.D.S. (PARIS), nt 47, West Street, Boston, Lines, has been nominated by the Socirtd Francaise d'Hygirne Scolaire et Universitaire, of Paris, to be their corresponding member in this country. He requests comnmnications on medical, dental and educational subjects which nfight be of interest for nlention in the Soci~tCs Bulletin of which the first number is due shortly. He will also be pleased to assist with information on the International Congress organised by the Socirt6 to be held in Paris from June 25th to 29th, 1947 (see I'FBI.i(: Ih.;~l'lll, Novcmher, p. 46).
THE MEDICAL OFFICER--PROSPECT AND INTROSPECT* By E. D. IRVINE, M.D.,.D.P.H.,
Medical Officer of Health, County Borough of Dewsbury T h e p u b l i c h e a l t h service m u s t feel some anxiety for the future. O n t h e one h a n d , the diagnostic a n d curative medical services are to be r e m o v e d f r o m the direction of local a u t h o r i ties a n d transferred to t h a t of regional boards, agents of the M i n i s t r y of Health. O n t h e other, t h e r e are political opinions w h i c h would reduce the status of w h o l e - t i m e public h e a l t h medical officers to t h a t of skilled technicians, mere executive i n s t r u m e n t s of State or local policy ; a n d others w h i c h would depress t h e i r incomes accordingly. T h e views of clinical consultants have b e e n given perhaps an u n d u e p r o m i n e n c e as c o m p a r e d w i t h the views of those whose s t u d y has been t h e a d m i n i s t r a t i o n a n d practice of public h e a l t h ; we can say this w i t h o u t disparaging the hospital consultants or general practitioners. M a n y in o u r b r a n c h of m e d i c i n e would claim t h a t their reasoned conclusions are as valuable as is t h e advice of the consultant for his particular patients--~vith the difference t h a t it is h a r d e r to p e r s u a d e those w i t h political power to e n s u r e the application of the c h o s e n r e m e d y t h a n it is to p e r s u a d e the m a n w h o has paid his c o n s u l t a n t ' s fee to accept the advice given. M a n y of o u r colleagues in t h e i r clinical fields (school health, m e n t a l deficiency, child welfare, a n d tuberculosis, to cite examples) are c o n t r i b u t i n g as m u c h to p u b l i c welfare as recognised clinical c o n s u l t a n t s . T h e s e c o n t e n t i o n s s h o u l d b e r e m e m b e r e d w h e n s h a p i n g the things to come.
The Steady Progress of Centralisation T h e transference of hospital a n d allied powers f r o m local authorities to the M i n i s t r y is b u t a f u r t h e r stage in the steady progress of centralisation. F o r years t h e r e has b e e n a drag f r o m local to regional g o v e r n m e n t ; first, in those services d e m a n d i n g large scale financial resources a n d n o w in all public h e a l t h services, e v e n t h o u g h they affect the lives of the people in t h e i r o w n h o m e s a n d in a m o s t personal way. M a n y medical officers (usually from large authorities) s u p p o r t these trends, m a n y (usually f r o m small places) oppose t h e m . Politicians, too, are divided. I t has to b e a d m i t t e d t h a t m a n y small authorities have failed to do t h e i r work. B u t b o t h the M i n i s t r y a n d c o u n t y councils have equally failed in n o t exercising t h e i r default powers in the P u b l i c H e a l t h Acts (Sections 3 2 1 , 3 2 2 o f t h e 1936 Act). Again, s o m e small authorities have b e e n h a m p e r e d b y i n a d e q u a t e financial resources in the absence of subsidisation f r o m national funds. W h e r e the a u t h o r i t y employs w h o l e - t i m e medical officers of h e a l t h the work has at any rate reached a reasonable standard. T h e Local G o v e r n m e n t Acts, 1929 a n d 1933, b y inference recognise this (section 59 in the former, a n d sections 111/112 in the latter). T h e fact is t h a t t h e work of an authority is as good as its officers. T h e transference of functions f r o m smaller to larger authorities (which if repeated often e n o u g h changes the s t r u c t u r e of local g o v e r n m e n t ) is n o t easily justified, especially w h e n the functions affect closely t h e personal lives arid h a b i t s of t h e people. A d m i n i s t r a t i o n at the centre reduces contacts between the authority, its officers a n d the p e o p l e ; rate d e t e r m i n a t i o n at the centre does n o t increase t h e a m o u n t of m o n e y collected n o r does it decrease the a m o u n t of m o n e y necessary. C h a n g e s w h i c h steadily reduce the n u m b e r of chief officerships m u s t seriously a n d adversely affect r e c r u i t m e n t . W e ought, nevertheless, to be grateful for t h e generous outlook of certain county councils a n d t h e i r c o u n t y medical officers (notably the W e s t Riding, L a n c a s h i r e a n d Surrey, a n d no d o u b t others) w h i c h have a d o p t e d schemes of divisional medical administration, giving so far as the law permits local influence a n d a u t h o r i t y to medical officers of h e a l t h w i t h i n the c o u n t y framework. T h e s e schemes will be u n d o u b t e d l y to the great advantage of all c o n c e r n e d a n d especially to the people. B u t t h e i r very w i s d o m is a n a r g u m e n t against the larger u n i t of a d m i n i s Abstract of Presidential Address to the Yorkshire Branch of the Society of M.O.H., October 26th, 1946.
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tration. There is no ideal unit for all local government purposes ; but a nearly all-purpose unit with both urban and rural characters of resources large enough to be economic and of area small enough to secure local interest and pride, and to maintain contact between the authority, staff and people, is surely the ideal solution. Maintaining Local Unity I conceive it to be one of the main functions of the M.O.H. to secure unity of purpose between the authority and the people in the local sphere. A uniform standard may not be desirable; what is necessary is a minimum standard which all must be encouraged to surpass. Centralisation or regionalisation of the local government service means increasing national control in local affairs ; we must decide for ourselves whether we think that a good thing. Despite the assurance even of Ministers, the signs suggest that we are witnessing the beginning of the end of local government as we have known it. T h e alleged advantages of the two-tier system of local government will, I believe, prove to be an illusion. Obligations and rights cannot be made effective without corresponding power, and with control from above interest at the lower level disappears. For this reason hospitals are right in demanding that their management committees shall have substantial powers. Uniformity imposed from above will stultify progress in hospitals as in the public health service. Nevertheless, local authorities will still be responsible for environmental hygiene and will no doubt attack the problems of social medicine. Our work may be different but not less interesting, less clinical perhaps, more social and still personal. It may develop more into research channels--the ascertainment of defect not only in the individual and his environment but also in the family and the home, and in the community. The care of the potential mother is of profound significance, the problem of population and re-creation of pride in family are of fundamental significance to the race and of immediate importance to the M.O.H. The homeless child and the broken family afford medical problems which we are in the best position to elucidate; the care of the aged has been neglected; the significance of social factors in the causation of many diseases--such as rheumatism, tuberculosis--is not clearly established; the epidemic character of many minor affections, and the domestic epidemic in respiratory and other infections, demand detailed s t u d y ; the meaning of place in family i n psychology, the biological significance of sudden death in child birth, the effect of artificial feeding and prematurity in later life, the balance of work and play in the making of personality are all problems which the public health service should help to solve. I n the more immediately practical sphere we have housing problems, the smoke nuisance, efficiency and nutrition in children and adults, control of intestinal infections, maintenance of pure food supplies and many more. We should not allow anyone to think that the M.O.H. has not a primary interest in food and housing, the two fundamentals of health. In all these matters the public health medical officer has important advisory as well as executive functions, and his contributions will be measured more by his significance in the former rather than in the latter sphere. Here his character and philosophic outlook, no tess than his scientific knowledge, make their vital contribution. We must influence those with political power without becoming avowed semi-professional politicians. The Community and the Individual
Health education remains par excellence an activity of the public health service ; we are undoubtedly in the best position to ensure and maintain an informed opinion on public health. Pressure by the people on their own behalf will secure much needed reform. I n recent years health education has become lopsided. We know the good work the Central Council for Health Educatior/ is doing, but V.D. and sex education have, in my view, taken too prominent a place in national health propaganda, due mainly to an approach to human problems
PUBLIC HEALTH, February, 1947 based solely on science and not informed by philosophy. There is a danger in thinking of man simply as a biologic unit set in an organic community. Making V.D. " j u s t one of the other infectious diseases " and " readily cured " is going too far in simplification. No one would not want to persuade towards early treatment, but our propaganda may even do what it sets out to prevent--increase its incidence. Sex education, too, seems to have passed the bounds of prudence. Instead of encouraging parents to undertake in their own way and time, to enlighten their children, we are indeed encouraging others, especially teachers, to take on this task; to be presented, it is feared, in a shorn of idealism. Too often in the past public health reforms have been initiated on behalf of the industrial effort and not from any primary consideration of individual needs. Progress has been fustified on the score of increased output. That outlook should go. Better health and greater happiness must be the first consideration. We should, as public health officers, always remember the t ~ m a n dignity of the individual. T h e community or society is becoming all important and individual rights are in danger of being submerged. The rights to live, to earn a livelihood, to family integrity, to a just share of the things of the earth, of access to truth are all inalienable. The right to health is implied in the first. There is an obligation on the State to secure to each these natural rights. Often we have to balance the needs of the community and the rights of the individual--secrecy in V.D., and in tuberculosis, the protection of the handicapped child in industry, the putting off work of patients possibly infected (e.g., the food worker affected by diarrhoea) are simple examples where conflicts may arise. The right to marry, the hardships of society on illigetimacy, the provision of meals free only if taken at school provide other instances. The subsidising of one section of the community (e.g., council tenants) of the expense of others equally poor, and the compulsory removal of families from one council house to another are others. Even superannuation poses a problem. If the right to work is absolutely conditional on health, then we have reached a dangerous point. With the increased safeguards of the National Insurance Act, the right to be employed should not be too strictly related to the requisites of a " first-class life." Vocational selection and guidance are much-discussed problems. There is here a grave risk of the imposition on individuals of the view and will of officers of the State and local authority. So long as it is advice and not pressure, no harm is likely, but we must beware always of compulsion. Vocational tests for entrants to the medical profession advocated by this branch some years ago seem to me a dangerous and unwise innovation. Again, accepting that child guidance clinics do good work, we should nevertheless insist that all working with children should have great regard for the personal dignity and integrity of the child. Above all we have the conflict between the parental rights and the rights of the State. In the past public health law and practice have been largely devoted to helping the parents, especially mothers, to rear children at home, and this (with the corollary that the homes must be in houses fit to live in) should be our aim. To mention two matters that are not entirely irrelevant. I have long thought that persons put off work for public health reasons and through no fault of theirs should be compensated ; and secondly, that rebating of council house rents to large and poor families should b e more generous and that the principle might be extended at public expense to other rent-controlled let houses. What of the doctor in all this ? Sir Alfred Webb-Johnson, P.R.C.S., declared (The Times, October 20th, 1946) " that we must ensure that the conditions of service in the national health service allowed intellectual freedom and gave character as much chance as cleverness. " T h e well-equipped clinician must possess the qualities of the artist, of the man of science, and of the humanist, but he must exercise them only in so far as they-subserve the recovery of the individual patient. It is a hard doctrine, but none the less true that this essential function of the doctor--the care of the given patient--might involve the forgoing of exactly
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scientific diagnosis, or the artistic perfecting of an operation or even of the interests of society at large." All this the doctor in private practice must be and do. But too often at present our colleagues in general practice think only of the patient and nothing of the community. T h e public health doctor remembering always that he is a doctor first, and a local government officer second, must be ever aware of his even more difficult task--to reconcile the needs of society with the rights of the individual.
THE ADMINISTRATIVE STRUCTURE OF THE FUTURE PUBLIC HEALTH SERVICE*
By J. S. G. BURNETT, M.D., D.P.H., Medical Officer of Health, Chadderton
Urban District
Much has been said about the future public health service and our new President gave us an admirable survey of the functions that would lie within the sphere of the public health department; but less has been said about the future of the individual medical officer of health, although all of us have been anxious about our own future and that of the younger members of our branch of the profession who would normally be expecting to obtain one of the junior administrative posts. The Meaning of '* Publie Health " Before discussing the future of the officer engaged in the public health service I should like to refer briefly to the nature of the service itself. T o many the term " public health " has meant latterly, in practice, the devoting of up to three-quarters of their working time to planning and administering schemes concerned with the treatment of the sick. T h e development of the hospital services consequent on the Local Government Act 1929 has been a tremendous step forward in the organisation of the medical services of this country, but it was not a public health process. We ourselves have recently pointed out that Mr. Bevan's Bill would be more appropriately named the National Sickness Service Bill. Again, there is a wave of enthusiasm for child health. Insofar as this means the investigation of heredity, the ascertainment of family and school environment and the pyschological and physical response of the child to these factors this truly is part of the public health. When it is interpreted to mean the treatment of defects discovered it is strictly a part of the sickness service. I recognise that under the old departmentalised system there was insufficient scope for the ambitious man or woman and the addition of therapeutic functions tended to ease the restrictive character of the original position. This problem still confronts us. T o me the term public health brings to mind certain historical facts. I am reminded that, as land drainage was effected in England, so malaria ceased to be endemic, and that the increase in population in the 18th century was not the result of an increased birth rate but was due to an increased expectation of life consequent upon an improved standard of living, especially in relation to developments in agriculture. I am reminded that tuberculosis mortality was falling steadily long before the institution of the tuberculosis service and that in the past seven years when the health services of this country were by no means at their highest pitch of efficiency, when men and women were working harder than they had done for years, but also when mass poverty was less than it had ever been before, the health of the nation has stood higher than it has ever done. My conception o f " the public health " is that poverty, overcrowding, bad housing in the home, the school and the factory, a filthy atmosphere, insufficient nutrition and a contaminated food supply, all in association with hereditary and infective factors and an inefficient individual mental stature, are the main factors in the production of ill health and that their elimination or control is the proper function of the public health service. Such a conception embraces preventive measures against the
* Paper to the North-Western Branch, Preston, November 8th, 1946.
occurrence of tuberculosis, rheumatism, peptic ulcer, deficiency diseases, bronchitis, industrial diseases and the infectious diseases, to mention only some of the present-day problems ; but not the treatment of established disease. Such a conception envisages the family as the focal point for investigation and for the application of remedial measures rather than the individual whether it be the infant, the school child, the mother or the aged. The National Sanitary Minimum Sir George Newman, in his " T h e Building of a Nation's Health," referring to the recommendations of the Royal Sanitary Commission of 1869, writes : - " T h e Commission's summary of the national sanitary minimum o f ' what is necessary for eivilised social life ' i n e v e r y l o c a l i t y is the grand inventory of that period : - I. T h e supply of wholesome and sufficient water for drinking and washing. II. T h e prevention of the pollution of water. III. T h e pr~.vision of sewerage and utilisation of sewage. IV. T h e regulation of streets, highways and new buildings. V. T h e healthiness of dwellings. VI. T h e removal of nuisances and refuse, and consumption of smoke. VII. T h e inspection of food. V I I I . T h e suppression of causes of diseases, and regulations in case of epidemics. IX. T h e provision for the burial of the dead without injury to the living. X. T h e regulation of markets, etc., public lighting of towns. XI. T h e registration of death and sickness." Moreover Newman states earlier that " speaking broadly, the Commission of 1843 found the existence of a serious national evil of insanitation and ill health, and recommended legislative remedy, whereas the 1869 Commission found that the remedy had proved ineffective, and recommended that " the present fragmentary and confused sanitary legislation should be consolidated." In other words the national sanitary minimum detailed above was recognised in 1843. Has the national sanitary minimum in every locality been achieved in 1946 ? The Structure of the Public Health Service U p to the outbreak of war in 1939 although the statutory duties of a medical officer of health were laid down by regulation, almost all whole-time holders of the office were in varying degree responsible for other work recognised to lie in the sphere of public health ranging from duties relating to the school medical service, to a complete immersion in hospital organisation and other measures related to the treatment of sickness. In the near future this will be changed and there will be two grades of officer, one whose duties are limited to his statutory responsibilities and a second whose duties will include the administration of the school health service and those other duties relating principally to child welfare and domiciliary disability outlined in Part I I I of the National Health Service Act. T h e anomalous feature of this fission is that it is based not on present-day populations, geographical considerations or efficiency of present services but on the dividing line of major or lesser authority established by the Local Government Act, 1888. A position has been created whereby the medical officer of health of a municipal borough such as Luton, with a population of 105,000 and a rateable value of £770,000, will come within the former grade of officer, wl~ilst his colleague of Smethwick, where there is a population of 74,000 and a rateable value of £420,000, will lie within the latter ,category, despite the fact that the former area dominates the surrounding countryside whilst the latter forms part of a congested urban sprawl. I make no comment on the position of the Urban District of Harrow, with a population of 211,550 and a rateable value of over £2,000,000, and the County Council of Rutland, with its population of 17,000 and its rateable value of £113,000. T h e pronouncements of more than one Minister of the Crown indicate that the Government does not look on such a position