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The next fifty years
THE NEXT FIFTY YEARS* By G. S. R O B E R T S O N
Chief Assistant School Medical Officer, Liverpool ALTHOUGH education became compulsory in 1870, it was in the last decade of the last century that we had first recorded in volume comments from the teachers as to the deplorable condition of children's health. In my own authority, like many others, as a result of the teachers' statements, a medical officer was appointed to investigate the physical state of the school children. I have copies of three reports, dated 1907, which this doctor, Dr. A. S. Arkle, wrote and which, when read in conjunction with the earlier Annual School Medical Reports, reveals a state of health amongst school children which is extremely difficult for us to envisage to-day. The early years of the School Health Service were preoccupied with arranging for, and giving treatment for, a wide range of disabilities and diseases, but during the 50 years which have since elapsed, there has been a gradual evolution from purely curative medicine to the present day, when a greater part of our time is given to preventive measures. If curative medicine be our only useful function, then I think that outside of some of the work which we do in connection with handicapped pupils, there would be little justification for continuing the Service much longer. Child health is such to-day that the need for curative medical treatment is getting less and less. With the apparent success of poliomyelitis vaccination we have reached a very high level of prevention in connection with infectious diseases. The general level of good nutrition amongst children and the development of chemotherapy and antibiotics further reduce the illness rate. The fact that cancer is now a relatively major cause of death in childhood, indicates the progress in the last 50 years. T R A I N I N G OF SCHOOL M E D I C A L O F F I C E R S The future function of the School Health Service is to ensure that the growing child makes his optimum mental and physical development. I can best describe what I envisage, as a desirable development of the Service, by describing what I think should be the postgraduate training of the future school medical officer, without considering the possible need for changes in the undergraduate medical curriculum. I consider that this medical officer should follow the complete undergraduate course and should do at least the preregistration training in connection with hospital work, to include at least some degree of knowledge of diseases of children. Pathology would play a very minor role and emphasis * A n abridged version of the Presidential Address to the School Health Service Group on 30th January, 1959. 339
340
PUBLIC
HEALTH
VOL.
LXXIII
NO.
9
would be placed upon a thorough knowledge of applied physiology. In the School Health Service doctors do not need to differentiate between the possible congenital lesions of the heart, for such investigations can be carried out to much better advantage with hospital facilities, but they should have that knowledge of heart function so that they can differentiate between what is normal and what is abnormal in their findings. Again, in connection with defective vision we deal mostly with physiological variations and, therefore, is not a thorough understanding of the functioning of the eye an essential? The theory and practice of refractions is not a difficult subject and all school medical officers should have this knowledge. Cases of defective vision associated with pathological conditions would, of course, be sent to a consultant. It is surely not sufficient for only some school medical officers to have some knowledge of child development in connection with the work of the ascertainment of handicapped children. All should have full knowledge of this field and such knowledge should be of daily use. Should not the development of skills be of interest to us? Should we not be interested in the child who does not take part in games, whether the cause be lack of skill or for psychological reasons? Most likely the cause will have elements of both. Have all a full knowledge of the newer physiology in connection with hearing? Without the application of this knowledge, many children with disabilities of hearing, are not going to have all possible done for them. Does not the supervision of the treatment of the children who suffer from cerebral palsy require a sound knowledge of the central nervous system ? I obviously do not need to take you through system after system to illustrate that, if we are going t o ensure that a child is to achieve his optimum in health, we are not in a position to aid him in doing so without this type of knowledge. I do not consider that extensive experience in paediatrics is a substitute for the knowledge I describe as necessary. Training in paediatrics is in too narrow a field for this purpose and the pathological, rather than the physiological, has been the main interest of the doctors concerned. Our need is rather to exclude the pathological before we turn to what ] consider our main function. Likewise, 1 do not think that general practitioners are any better qualified, nor do 1 think that part-time work is a satisfactory arrangement. This is work for specialist medical officers. It may well be that, in the course of time, emphasis in medical education will so cover normal function and development that both paediatricians and general practitioners will be qualified for this work. l find that amongst the general public one more frequently hears, in cases such as coronary thrombosis, diabetes of overweight, hypertension, etc., remarks asking why their doctors have not advised them about the need to diet, etc., before it led to the diseased condition. This alone will lead-doctors to take a greater interest in prevention. 1 can contemplale the work of the
THE
NEXT
FIFTY
YEARS
341
School Health Service being done by general practitioners when they practise preventive medicine to such a degree that there will be no need for our services, but I cannot foresee that this will happen in the near future. SCHOOL NURSING The function of the school nurse is changing, along with that of the school medical officer. In the efforts to ensure that a child is reaching the optimum in health, the school nurse has a very important part to play. In my opinion, this part can only be played properly if her work is carried out with the closest possible liaison with her medical officer. She should bring to the medical officer full knowledge of the home background of the school child; she should be present at the medical examination of the children under her care, not to dress and undress children and do odd jobs for the doctor, but to take an active part in the examination. From her regular visits to school she should have considerable knowledge of the child's adjustment to his school environment and she should be free to learn the doctor's opinion concerning the child as the result of the examination. Her duty should be to continue the necessary supervision of the child, both in the school and in the home, and to bring the child back to the doctor as, and when, found to be desirable. It follows, therefore, that if the school medical officer is doing full-time work in school medicine the nurse should do likewise. In my opinion, where numbers of school children are sufficient, the school medical officer has plenty of scope for his skill within the Service and, where this pertains, the school nurse should also be confined to this Service. One hears much about the "omnibus" health visitor, who carries out all the duties in her district. In a thickly populated area, without a very great increase in the supply of health visitors, I cannot conceive but that such an arrangement must be a handicap to the efficient carrying out of the work. However, in a district where the population is low and where the factor of travel is all important, then, as a practical necessity, the most economical arrangement would be for the health visitor to be all-purpose. S C H O O L N U R S E S AND M E D I C A L I N S P E C T I O N S The question is raised from time to time as to whether or not nurses could carry out school health surveys and that only selected cases should be seen by the doctors. The assumption would appear to be that the less the disability the more easily it is discovered and also that the nurses have had training in medicine. In Liverpool, we have carried out an investigation on the value of a questionnaire to parents in relation to the health of their children coupled with the value of a school nurses' survey. Both of these procedures proved to have a certain value in that they facilitated the school medical officers' examinations. They were no substitute for the medical officers' inspections, but by the selection of children by the qucslionnairc and school nurses' survey the doctor distributed
342
PUBLIC
HEALTH
VOL.
LXXIII
NO.
9
her time more economically. Against this economy must, of course, be set the time of the school nurses. Financially there would not be a great saving and, at present, qualified school nurses are in short supply. HEALTH
EDUCATION
There is need for much expansion in this field. Much good work has been, and is being, done in the individual approach to parents. There is no doubt that to give health education to a parent, based upon the parent's own child, is very valuable. Whereas the School Health Service, as organised in this country, is, in my opinion, superior to that of any other country in the world, I do think that in one aspect the Americans are taking the lead, viz., in the teaching of human biology. If education has, as its aim, a fuller and happier life for the individual, I am sure that we would all agree no factor is more important than the question of good health. It is difficult, therefore, to understand why a knowledge of the body function should not be considered an essential part in the education of every individual. Short of this ideal, that children throughout their school lives are given a knowledge of human biology, much can be achieved if school doctors and school nurses take a part in the teaching of hygiene in the schools under their care. In my own authority we have not attempted to plan this work on a fixed programme but rather to offer readily the help of members of the school health staff to any schools which wish their help. The demand for this help is increasing and, in fact, particularly in some secondary modern schools, is now being used quite extensively. The satisfactory working of a school health department has always depended upon good co-operation with the teachers in the schools. The type of programme which I have in mind for the future will depend more than ever before upon such co-operation. My experience assures me of the teachers' willingness to do all they can to promote children's welfare but I think that we probably need to tell them more of our present aims. It was apparent in the past why we wished to treat obvious physical illness but it requires explanation as to why we should be interested in the care of the child with no disease.
Chief Assistant School Medical Officer, Liverpool ALTHOUGH education became compulsory in 1870, it was in the last decade of the last century that we had first recorded in volume comments from the teachers as to the deplorable condition of children's health. In my own authority, like many others, as a result of the teachers' statements, a medical officer was appointed to investigate the physical state of the school children. I have copies of three reports, dated 1907, which this doctor, Dr. A. S. Arkle, wrote and which, when read in conjunction with the earlier Annual School Medical Reports, reveals a state of health amongst school children which is extremely difficult for us to envisage to-day. The early years of the School Health Service were preoccupied with arranging for, and giving treatment for, a wide range of disabilities and diseases, but during the 50 years which have since elapsed, there has been a gradual evolution from purely curative medicine to the present day, when a greater part of our time is given to preventive measures. If curative medicine be our only useful function, then I think that outside of some of the work which we do in connection with handicapped pupils, there would be little justification for continuing the Service much longer. Child health is such to-day that the need for curative medical treatment is getting less and less. With the apparent success of poliomyelitis vaccination we have reached a very high level of prevention in connection with infectious diseases. The general level of good nutrition amongst children and the development of chemotherapy and antibiotics further reduce the illness rate. The fact that cancer is now a relatively major cause of death in childhood, indicates the progress in the last 50 years. T R A I N I N G OF SCHOOL M E D I C A L O F F I C E R S The future function of the School Health Service is to ensure that the growing child makes his optimum mental and physical development. I can best describe what I envisage, as a desirable development of the Service, by describing what I think should be the postgraduate training of the future school medical officer, without considering the possible need for changes in the undergraduate medical curriculum. I consider that this medical officer should follow the complete undergraduate course and should do at least the preregistration training in connection with hospital work, to include at least some degree of knowledge of diseases of children. Pathology would play a very minor role and emphasis * A n abridged version of the Presidential Address to the School Health Service Group on 30th January, 1959. 339
340
PUBLIC
HEALTH
VOL.
LXXIII
NO.
9
would be placed upon a thorough knowledge of applied physiology. In the School Health Service doctors do not need to differentiate between the possible congenital lesions of the heart, for such investigations can be carried out to much better advantage with hospital facilities, but they should have that knowledge of heart function so that they can differentiate between what is normal and what is abnormal in their findings. Again, in connection with defective vision we deal mostly with physiological variations and, therefore, is not a thorough understanding of the functioning of the eye an essential? The theory and practice of refractions is not a difficult subject and all school medical officers should have this knowledge. Cases of defective vision associated with pathological conditions would, of course, be sent to a consultant. It is surely not sufficient for only some school medical officers to have some knowledge of child development in connection with the work of the ascertainment of handicapped children. All should have full knowledge of this field and such knowledge should be of daily use. Should not the development of skills be of interest to us? Should we not be interested in the child who does not take part in games, whether the cause be lack of skill or for psychological reasons? Most likely the cause will have elements of both. Have all a full knowledge of the newer physiology in connection with hearing? Without the application of this knowledge, many children with disabilities of hearing, are not going to have all possible done for them. Does not the supervision of the treatment of the children who suffer from cerebral palsy require a sound knowledge of the central nervous system ? I obviously do not need to take you through system after system to illustrate that, if we are going t o ensure that a child is to achieve his optimum in health, we are not in a position to aid him in doing so without this type of knowledge. I do not consider that extensive experience in paediatrics is a substitute for the knowledge I describe as necessary. Training in paediatrics is in too narrow a field for this purpose and the pathological, rather than the physiological, has been the main interest of the doctors concerned. Our need is rather to exclude the pathological before we turn to what ] consider our main function. Likewise, 1 do not think that general practitioners are any better qualified, nor do 1 think that part-time work is a satisfactory arrangement. This is work for specialist medical officers. It may well be that, in the course of time, emphasis in medical education will so cover normal function and development that both paediatricians and general practitioners will be qualified for this work. l find that amongst the general public one more frequently hears, in cases such as coronary thrombosis, diabetes of overweight, hypertension, etc., remarks asking why their doctors have not advised them about the need to diet, etc., before it led to the diseased condition. This alone will lead-doctors to take a greater interest in prevention. 1 can contemplale the work of the
THE
NEXT
FIFTY
YEARS
341
School Health Service being done by general practitioners when they practise preventive medicine to such a degree that there will be no need for our services, but I cannot foresee that this will happen in the near future. SCHOOL NURSING The function of the school nurse is changing, along with that of the school medical officer. In the efforts to ensure that a child is reaching the optimum in health, the school nurse has a very important part to play. In my opinion, this part can only be played properly if her work is carried out with the closest possible liaison with her medical officer. She should bring to the medical officer full knowledge of the home background of the school child; she should be present at the medical examination of the children under her care, not to dress and undress children and do odd jobs for the doctor, but to take an active part in the examination. From her regular visits to school she should have considerable knowledge of the child's adjustment to his school environment and she should be free to learn the doctor's opinion concerning the child as the result of the examination. Her duty should be to continue the necessary supervision of the child, both in the school and in the home, and to bring the child back to the doctor as, and when, found to be desirable. It follows, therefore, that if the school medical officer is doing full-time work in school medicine the nurse should do likewise. In my opinion, where numbers of school children are sufficient, the school medical officer has plenty of scope for his skill within the Service and, where this pertains, the school nurse should also be confined to this Service. One hears much about the "omnibus" health visitor, who carries out all the duties in her district. In a thickly populated area, without a very great increase in the supply of health visitors, I cannot conceive but that such an arrangement must be a handicap to the efficient carrying out of the work. However, in a district where the population is low and where the factor of travel is all important, then, as a practical necessity, the most economical arrangement would be for the health visitor to be all-purpose. S C H O O L N U R S E S AND M E D I C A L I N S P E C T I O N S The question is raised from time to time as to whether or not nurses could carry out school health surveys and that only selected cases should be seen by the doctors. The assumption would appear to be that the less the disability the more easily it is discovered and also that the nurses have had training in medicine. In Liverpool, we have carried out an investigation on the value of a questionnaire to parents in relation to the health of their children coupled with the value of a school nurses' survey. Both of these procedures proved to have a certain value in that they facilitated the school medical officers' examinations. They were no substitute for the medical officers' inspections, but by the selection of children by the qucslionnairc and school nurses' survey the doctor distributed
342
PUBLIC
HEALTH
VOL.
LXXIII
NO.
9
her time more economically. Against this economy must, of course, be set the time of the school nurses. Financially there would not be a great saving and, at present, qualified school nurses are in short supply. HEALTH
EDUCATION
There is need for much expansion in this field. Much good work has been, and is being, done in the individual approach to parents. There is no doubt that to give health education to a parent, based upon the parent's own child, is very valuable. Whereas the School Health Service, as organised in this country, is, in my opinion, superior to that of any other country in the world, I do think that in one aspect the Americans are taking the lead, viz., in the teaching of human biology. If education has, as its aim, a fuller and happier life for the individual, I am sure that we would all agree no factor is more important than the question of good health. It is difficult, therefore, to understand why a knowledge of the body function should not be considered an essential part in the education of every individual. Short of this ideal, that children throughout their school lives are given a knowledge of human biology, much can be achieved if school doctors and school nurses take a part in the teaching of hygiene in the schools under their care. In my own authority we have not attempted to plan this work on a fixed programme but rather to offer readily the help of members of the school health staff to any schools which wish their help. The demand for this help is increasing and, in fact, particularly in some secondary modern schools, is now being used quite extensively. The satisfactory working of a school health department has always depended upon good co-operation with the teachers in the schools. The type of programme which I have in mind for the future will depend more than ever before upon such co-operation. My experience assures me of the teachers' willingness to do all they can to promote children's welfare but I think that we probably need to tell them more of our present aims. It was apparent in the past why we wished to treat obvious physical illness but it requires explanation as to why we should be interested in the care of the child with no disease.