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The officer of health
PUBLIC HEALTH, December, 1946 THE
OFFICER
OF H E A L T H *
By C. METCALFE BROWN, M.D., D.P.H., BARRISTER-AT-LAw,
Medical O~cer of Health, City of Manchester T h e unusual title of this address has been chosen for two reasons. First, it has a historical significance in that the appointment of the first Medical Officer of Health for Manchester was advertised as that of Officer of Health, the advertisement stating " that the Corporation were prepared to receive applications from gentlemen, whether medical or otherwise, who might be desirous of obtaining the appointment of Officer of Health for this city at a salary of £500 per annum." Mr. John Leigh, a Manchester surgeon, was appointed from a short list of four medical men, but amongst the other candidates were a colonel, a major, and a lieutenant of the British Army, all non-medical, two sanitary inspectors, a surveyor and a clergyman. T h e appointment was made in 1868, 21 years later than the appointment in Liverpool of the first Medical Officer of Health in this country--on the centenary of which we, as a Branch, will wish to accord our hearty congratulations .to the City of Liverpool and to celebrate in a manner fitting to the great occasion. T h e other reason for the choice of title is that it will serve to remind us that although it is vital that medical men, with adequate medical assistance, should be in charge of the public health departments, the bulk of the manifold duties are carried out, and in a highly efficient manner, by non-medical members of the staff, who are in truth officers of health working in conjunction with their medical colleagues. In this connection, I would commend the advantages of the appointment of lay administrative officers. Several public health departments have had these officers for many years and in Manchester, and no doubt elsewhere, the appointment has proved to be a happy and successful one, and has ensured a high standard of efficiency in administration and at the same time has relieved the medical staff of the unnecessary burden of many nonmedical matters. Public health officers, like the medical profession generally, and indeed other professions, find themselves this year at a crucial point as a result of the provisions of the National Health Service Bill. T h e last great change in public health administration following the Local Government Act, 1929, caused a vast addition to the responsibilities of departments, which has resulted in the occupation of at least half of the time of many medical officers of health in hospital administration. T h e new legislation bill do more than reverse the process for we lose the infectious diseases hospitals and the sanatoria that have been administered by medical officers of health, if not from time immemorial, at least before the commencement of the professional careers of most of the public health officers of to-day. These are serious losses, and yet I must confess that the transfer of the administration of the hospitals to regional hospital boards is sound policy, although one would be less than human if one did not have a pang of regret after years of experience of hospital administration under the aegis of local authorities. But it is not my purpose to discuss at length the many merits and the few possible demerits of the Bill. I propose to invite you to look forward rather than back, to consider the new duties and the changed duties and the new opportunities presented to us under the new regime. Hospitals It is inevitable that the transfer of hospital administration will mean also the transfer of many public health officers to the service of the regional hospital boards and, indeed, it is no exaggeration to say that the efficiency of the administration of these boards would be in grave jeopardy without the services of existing local authority officers possessing, as they do, wide experience in hospital matters. In the words of the Minister of Health at the annual luncheon of the Society of Medical Officers of Health in September, 1946, " It is our intention # Presidential Address to the North-Western Branch, Society of Medical Officers of Health, Manchester, October llth, 1946.
51 to try to use, so far as they will allow themselves to be used, all the vast body of health workers who have built up such a splendid tradition. We do not want to discard in any way the services of those who have accumulated so much experience." T h e staffs of voluntary hospitals will also no doubt be called upon to contribute their quota of the necessary staffs, and one may safely expect that the new staffs, composed of recruits from both types of hospital service, will together provide in time a high standard of service based on an unrivalled pool of variegated experience. Here, many will find the continuation of their life-work and many will find new and satisfying careers. T h e bulk of the present public health medical officers will remain in the public health departments, but although direct hospital administration will have gone there is no doubt that the spirit and intention of the Bill is to encourage the closest collaboration between the public health service and the new hospital service and indeed the most relevant criticism of the new Bill might be that having gone so far it might well have gone further and placed public health administration and other types of medical administration in the same hands as hospital administration and so have achieved unity of administrative control. T h e practical difficulties of such a course at the present time are easy to understand but it is to be hoped that the present step, admittedly a long one, is but the first of a series of steps towards the goal of a unified medical service. Sir Allen Daley has expressed the hope that the medical officer of health will continue to be associated with his hospital colleagues, for example, by membership of regional hospital boards and hospital management committees and collaborating in the development and maintenance of the hospital and specialist services. If that indeed comes to pass, then the medical officer of health will still be much occupied with hospital matters, although relieved of the detail of day-to-day administration. Child Health Servlees T h e Maternity and Child Welfare service and the School Health service together form the most important part of the work, present and future, of the public health officer, and although much has been done there is room and need for extension and improvement of our existing services. Who can say, for example, that the standard of school hygiene in his area is satisfactory ? In some areas it would be hard to find a single school which conformed to good standards. In this sphere alone there are boundless opportunities of using our influence for the sound planning of the many new schools to be erected and=we shall do well to remember that on the environmental side of our work, whilst the provision of new houses and the reconditioning of existing ones is the most urgent need, the need for decent and healthy school buildings is nearly as urgent and important. Lower in the priority list but still high up is the need for the suitable housing of the maternity and welfare service, and although we could all animadvert with good cause and some impatience on the inadequacy in q~ality and size of the welfare centres the new Act will provide an opportunity of experimenting with Health Centres, I hope, in conjunction with general practice. I trust, too, that the experimental period will not be too prolonged and that an increasing availability of labour and material will within a reasonable space of time give us premises worthy of their function in place of the many exasperating places that disgrace our service. But, just as in the history of medicine much pioneer research has been carried out with a minimum of equipment, so much good work goes on in spite of our disadvantages and important though the quality of premises may be, the quality of the staff is of much greater importance, and if that quality is to be maintained and improved an early rearrangement of the administrative structure is necessary. I believe that the right way lies in a fusion, nationally decreed, of the Maternity and Child Welfare Service and the School Health Service. T h e new legislation on Education and Health ensures that the two health services shall be administered by the same authority. It is becoming more and more difficult to discern the difference in function between a day nursery and a nursery school, and
PUBLIC HEALTH, December, 1946
52 the number of convalescent homes for children which become special schools overnight is increasing. These trends together are pointing the way--the way to a unified Child Welfare service--to the integration of the administratively disintegrated child. The various specialisms confined mainly to the child at school should be widened to include the child at home, at the welfare centre, and in hospital, and similarly the paediatrician in hospital and the welfare centre medical officer should be allowed to break their bonds and deal with the whole child, irrespective of age, condition or environment. A Chair of Child Health at the Regional University is an essential ingredient of this recipe and it is an encouraging sign of the willingness of local authorities to collaborate with each other that, at Manchester University, a Department of Child Healt~ is shortly to be inaugurated, supported financially not by Manchester alone, but by the major local authorities of the whole area to be served. The functions of the department should be advisory, teaching and research but not executive. On that basis the professor and his staff, which should include on a part-time basis several of the local authority officers now engaged on child health, should be certain of a welcome in all the child health sections o f the health departments, as well as those at present conducted by voluntary agencies. T h e beneficial effect of this democratic foundation will assuredly be that there will be a closer knitting together, not only of staffs and sections of the public health departments but of one department with another and of the public health service of the region as a whole with the children's hospitals under voluntary management. We have been later than other regions in achieving a Chair of Child Health, but it may well be that the unique combination of local authorities though somewhat slower in initial action, may prove to have found the most successful method of collaborating on child health with each other and with the university. In the same way as the medical officers, the health visitor and school nurse should merge their respective spheres and pursue their common aim together. Here again we should endeavour to be economical of specialist skill and use trained nursing personnel as far as possible for the duties of their profession and cover the other and equally important duties of the service by other specialists in increasing numbers--specialists trained in social science. And just as the duties of the medical officers of health evolved as medical sociology grew in importance and the original sanitary preoccupations passed to the care in general of the sanitary inspector, so the sanitary inspector is adding to his environmental duties increasing responsibilities in relation to the community as a social efitity--to the man as well as to his home and his workshop. And so we get the link between the health visitor and the social worker, and the link between the social worker and the sanitary worker, all working in conjunction with the clinician and the medical and non-medical administrator. This is a tidier picture than the present one, although we must avoid administrative tidiness for the sake of mere tidinessklet us strive for high ~fficiency tempered with humanity. Industrial Medicine
Our responsibilities already embrace the home environment, the welfare of the children and the domiciliary midwifery service and to these will shortly be added the duties of providing a service of home helps and of home nursing. Our responsibilities in the homes will be as important as they will be comprehensive. Similarly, we have responsibilities in relation to school hygiene in the workplaces of the children. But curiously, although we have some duties in relation to factories and workshops, the sphere of industrial medicine remains as a thing apart and the time is surely ripe for giving this important section of community service its rightful place in the public health scheme. Here is another step for the near future, a shorter and easier one than the long step we are about to take. Poor Law
It is likely that new legislation will shortly be introduced in relation to Poor Law, legislation which is long overdue, because
whilst it is true that there have been fairly recent Poor Law Acts, they have been consolidating rather than reforming and reform is urgently needed. How such new legislation will affect public health administration it is impossible to say but we shall no doubt inherit some of the estate of the dying administration. For many years in Manchester the administration of the main public assistance institutions has been delegated to the Public Health Committee, the masters of the institutions being responsible to the medical officer of health in the same way as the medical superintendents of the municipal hospitals. This system has worked with great smoothness and it is possible that it may be the forerunner of a national system. T h e care of aged persons, who represent an increasing proportion of our population, is so obviously a matter of welfare administration that the public health departments, with their increasing welfare trends, would appear to be the logical direction in which transfer should be made. Infectious D i s e a ~ s
Medical officers of health of both large and smaU areas could hardly do other than regret the departure of the isolation hospitals from their control, but, sorrowful though it may be, it is nevertheless logical that having decided on the principle of the removal of therapeutic services from the rest, the isolation hospitals should join company with all the other hospitals. Fortunately, the duties in relation to the prevention of infectious diseases and to epidemiology remain with us. I recall that when I was a medical student diphtheria immunisation was recognised as advantageous and reliable, yet after all these years we are now in the throes of trying to achieve a high percentage of immunised children and it is only within the last few years that an appreciable diminution of the number of deaths from diphtheria has occurred. It is a sad commentary on the inefficiency of health education in the past and of the difficulty of converting public opinion. Still, we are succeeding at last and a few more years of intensive effort should make diphtheria deaths as rare as scarlet fever deaths. Whooping cough immunisation would appear to be the next task and an interesting one it will be. Whooping cough is much more fatal than either measles or scarlet fever and the occurrence of this disease in a family is productive of much disorganisation and distress, leaving lifelong effects in many cases. American experiments with vaccines appear to have produced favourable results, but trials in this country have been inconclusive and the Ministry of Health is not yet, to quote the Chief Medical Officer, " sufficiently convinced of its value to justify a mass immunisation campaign." What are we to do ? Most of us probably feel that whooping cough prophylaxis is worth while and are prepared to advise a trial in individual cases, but in the light of the evidence and in particular of the opinion of the Ministry of Health, we may well hesitate to put the seal of approval on a method which may yet prove to be valueless although my own opinion~is that it will prove to be of value. Our clear duty, is to establish once and for all the efficiency of Whooping~cough prophylaxis and to that end the Medical Research Council, in conjunction with Manchester, Tottenham and Wembley, are commencing a trial which we hope may provide the answer. A quantity of Sauer's vaccine is to be made available in Manchester. Parents of infants are being asked to co-operate in this trial, which is explained frankly to them. The vaccine will be administered to half of these infants and the other half will get anti-catarrhal vaccine. All the children will be kept under close observation for a number of years and the incidence of whooping cough carefully noted. In order to eliminate psychological factors in estimating results, neither the parents nor the officers administering the vaccine will know whether a particular child has or has not received Sauer's vaccine and so a true scientific control will be achieved. If the results are what we hope they will be, the ultimate effect on the community will be inestimable. Here, then, is but one example of the type of work that lies before us all. T h e advent of chemotherapy has profoundly affected our therapeutic measures a n d the facility with which the synthetic chemist is able to modify drugs at will, and in predeter-
PUBLIC HEALTH, December, 1946 mined directions is a guarantee that the future will provide an ever-expanding armoury of new weapons. But these drugs are available for prevention as well as for cure, and Cruickshank's article on "Chemoprophylaxis in the control of bacterial infections," in the July issue of the Monthly Bulletin of the Ministry of Health and Public Health Laboratory Service, is invaluable not only as a summary of what has gone before and of how we can use the new knowledge, but also as an indication of the possibilities with regard to things to come, not as a cure-all in place of our present methods but ancillary to them. As Cruickshank says, " These drugs must not be used as a substitute for good hygiene." Recent years have witnessed the attainment of a high standard of efficiency of the Public Health Laboratory Service and progress is certain to continue. Collaboration between the scientists in the laboratory and the field workers in the public health departments is increasing and much excellent work has been carried out and fully reported, most of it capable of immediate practical application. Here lies an avenue of approach to our real work which many of us are already using and which all of us should use and with increasing frequency. T h e resultant team has unlimited opportunities before it, and there is much virgin soil to be ploughed. Environmental Conditions
T h e progressive improvement of basic environmental conditions has allowed us to turn our thoughts to matters which, given these conditions, were of even greater importance. But, the time has come when it might be well for us to give renewed attention to environment, not to detailed matters now delegated to sanitary inspectors but rather to questions of wide policy on a regional or national basis. We are all, unfortunately, only too acutely aware of the present grave position with regard to the high number of unfit houses in our respective areas and of the long period of years which must elapse before new housing overtakes the need. But the fact that millions of new houses are to be built does give us an opportunity of using our influence in the direction of better standards of house building and of fostering public opinion with regard to them. T h e need for smoke abatement is still as great as ever and the approach should be preventive in preference to therapeutic, although treatment will still be needed for a long time to come. We must make every effort, in conjunction with fuel and engineering experts, to determine the most efficient kind of apparatus for heating houses so that we may take advantage of the unprecedented opportunity presented to us by the building of the very large number of houses in years to come. T h e r e is no shortage of ideas--let us do our utmost to get them put into practice. Let us lend our aid to the engineers who are advocating district heating--the supply of warmth and constant hot water to houses from a central station--so that the standard of hygiene and comfort of these houses may be raised, that fuel may be used more efficiently and atmospheric pollution reduced.; Let us pursue the idea o f smokeless zones, let us recommend the use of smokeless fueLand,the iilspection and approval of industrial heating apparatus and the increased use of electricity and gas for heating and cooking. We may be sure of much support in these efforts by the National Smoke Abatement Society and the Regional .Smoke Abatement Committees of local authorities, a number of which are in active existence. Social and Emotional Factors
Much that I have already mentioned has loomed large in the professional thoughts of most of us and such action as has been open to us has been taken in many areas, although there is still much we can do. T h e wider problem of the ascertainment and remedy of psychological causes of ill health will form for many years one of the most important parts of our work. Fortunately, but only recently, the view has become widely held that physical ill health and psychological ill health are closely related and indeed are inseparable. For example, the so-called psychosomatic illnesses are creative of much distress and disability and require much consideration and
53 research. As field workers, we are in the best possible position to initiate and conduct such research. Similarly, the War has shown the extraordinary effect of a controlled and improved nutrition on the health of the community and we have a clear duty to support and foster every scheme which will assist in the maintenance and improvement of nutrition, for let us face the position quite frankly--most of our plans must come to nought in face of nutritional deficiency. Medical Statistics
It must be confessed that medical proficieney and statistical competence, except in a few outstanding cases, are rarely found in the medical profession. This undesirable state of affairs is not surprising in that the medical curriculum, quite properly, trains us as individualists with a humanistic outlook. T o attempt to train medical students as statisticians would inevitably embarrass either their medical or statistical studies or perhaps both. Medical graduates are normally fully occupied in hospital:, practice in their earlier years and in their later years are so much absorbed in their professional work that they are unable to spare the time to train in statistics. T h e only remedy would appear to be that those whose professional work does include statistics should spare some of their undoubtedly limited time to make themselves, if not expert statisticians, at least reasonably competent in statistical methods. Whether that may prove to be practicable or not, it would undoubtedly be advantageous if medical officers of health and their staffs did everything possible to raise the standard of statistical work in the public health departments. T h e need for such improvement is clear if we are to marshal effectively the facts so laboriously obtained in our work in research. T h e Monthly Bulletin is an invaluable ally in this direction, encouraging as it does co-operation between the departments and the laboratories, stimulating us and directing our attention to fresh fields and showing us by precept the best methods of investigation. I would go so far as to say that a set of the Monthly Bulletin is equal in importance, from our point of view, to any set of documents to be found in our departments. Those departments that possess a complete set of issues since they were first printed in November, 1941, are fortunate, wise and prudent, particularly in view of the fact that several of the earlier numbers are now unobtainable. It behoves us, therefore, to cherish the copies we possess and, in cherishing them, to consult them frequently. Health Education
As health officers we are leaders in the task of educating the public in health matters but if a leader is too far ahead of his company his leadership is just as ineffective as the type of leadership shown by the Duke of Plaza-Toro : - " He led his regiment from b e h i n d - H e found it less exciting." In other words, we must not get too far ahead of public opinion, although we should always be in front of it. Fortunately, modern methods of publicity will tend to facilitate our work in this respect, and the following are some of the most promising methods : - (1) T h e fullest co-operation with the Central Council for Health Education and their officers. T h e propaganda material issued by the Council is excellent in quality and quantity, and if there is any defect in the present arrangements it is that the distribution of this excellent material is not sufficiently wide. We are all doing our best to distribute the Council's publications within our own service and to some extent beyond it, but means should be devised for ensuring its penetration far beyond existing circulations. This means not only persistent efforts on the part of officers but increased financial support of the Council by the local authorities. (2) T h e increasing use of newspaper advertisements and articles. As newsprint becomes more and more available our opportunities will increase correspondingly. (3) T h e u s e of xadio propaganda by officers of the Ministry of Health and of representatives of local authorities. (4) Loud speaker vans for making announcements and
PUBLIC HEALTH, December, 1945
54 applying persuasion at the very h o m e s of the people. T h i s is particularly useful in t h e c o n d u c t of campaigns s u c h as t h a t for d i p h t h e r i a i m m u n i s a t i o n . (5) T h e use of posters a n d bills on p u b l i c t r a n s p o r t vehicles w h e r e the m a n a g e r s of t r a n s p o r t u n d e r t a k i n g s can b e persuaded to p e r m i t t h e m . (6) T h e increasing film-going t e n d e n c i e s of the general p u b l i c give us an o p p o r t u n i t y of a p p r o a c h i n g t h e m and ensuring t h a t o u r publicity will reach t h e m . T h e m e t h o d is expensive a n d b y n o m e a n s easy b u t t h e chances of successful appeal to p u b l i c opinion are u n d o u b t e d l y high. I k n o w it is easy to advocate these m e t h o d s b u t difficult to apply t h e m , b u t we h a v e k n o w n difficulties before and have successfully o v e r c o m e t h e m . Teaching T h e N a t i o n a l H e a l t h Service Act will b r i n g to t h e hospital service t h e valued interest a n d co-operation of t h e universities as n e v e r before a n d a corresponding interest of t h e universities in t h e practical work of the o t h e r medical services would b e equally welcome. T h i s spirit of co-operation can b e fostered b y willingness to teach university s t u d e n t s a n d m a n y of the public health d e p a r t m e n t s are already taking an eager and i m p o r t a n t p a r t in this excellent work. O n e hesitates to ask already o v e r b u r d e n e d staffs to u n d e r t a k e these t i m e - c o n s u m i n g duties b u t t h e rewards are great. W e have t h e satisfaction of helping to t r a i n the intellectual workers of t h e f u t u r e and at t h e same time to reap great advantages as a result of t h e stimulation t h a t teaching gives to the teacher. I n conclusion, t h e r e are some w h o fear as a result of the great t r a n s f e r of work a b o u t to take place t h a t t h e p u b l i c h e a l t h d e p a r t m e n t s will d i m i n i s h in influence, size a n d importance. I h o p e I have h e l p e d to d e m o n s t r a t e t h a t o n the contrary t h e future holds for us actual work a n d potential work of greater i m p o r t a n c e even t h a n o u r work of t h e present, t h e d e p a r t m e n t s will increase r a t h e r t h a n decrease a n d for those w h o have t h e will, the energy a n d t h e r i g h t outlook, there are b o u n d l e s s o p p o r t u n i t i e s of satisfying service in t h e years t h a t lie before us.
THE U N P R O T E C T E D TRAVELLER, OR, T H E RISKS OF GOING TO WORK I take this opportunity of quoting a paragraph which appeared in my Annual Report for the year 1930:-" Inasmuch as a very large proportion of the inhabitants work in the City and County of London, it is aptly described as a ' dormitory of the Metropolis.' By no stretch of the imagination can it be claimed that Leyton is well served as regards facilities for travelling by rail, and the extent of the overcrowding in the trains to and from London during ' r u s h h o u r s ' cannot be regarded as other than a potent factor in the spread of communicable disease. Your Council has wisely made representations to the Railway Company with a view to the provision of better facilities for the travelling public, but apparently without avail. The conditions under which our City workers earn their living are often far from ideal as regards light, ventilation, noise, overcrowdPag, etc. Although ~ Health Authorities and the Home Office possess statutory powers tor controlling the conditions of work in factories and workshops, no such powers exist for the protection of the great body of clerical workers, etc., in the offices of the City. ' The tired City-worker' is an expression in everyday use, and there can be little doubt that the conditions of work in the City---coupled with the nervous strain associated with journeys to and from work--play a considerable part in the production of that ' tired' feeling. All City workers may not return from work bodily tired, but all tired City workers return with diminished bodily resistance against infection; and it is in this state of impaired resistance that they are compelled to run the gauntlet of massive doses of infection in dirty, stuffy and overcrowded railway compartments." Not only has there been no improvement since that time, but there has been a marked deterioration in the appalling conditions under which Leyton residents have had to travel to and from London during and since the war. I have always considered that overcrowded public transport vehicles were the most fruitful source of respiratory infection; and, until such time as travelling conditions are rendered less dangerous, there is much to be said in favour of the continuatioo of the war-time poster " I s your journey really necessary? "--Dr. ANnREw FoaaEsr (M.O.H., Leyton M.B.) in his Annual Health Report for 1945.
THE
PECKHAM
PIONEER
HEALTH
CENTRE*
By G . SCOTT WILLIAMSON, M.C., M.D., CH.B., L.R.C.P., L.R.C.S., ED., Medical Director, The Pioneer Health Centre, Pechham M y collaborators a n d I, after some years of work on colonies of rats, realised t h a t we could n o t p u r s u e o u r e x p e r i m e n t s o n animals any further. H o w on e a r t h were we going to get h u m a n beings to come into contact w i t h scientists ? All we h a d to sell t h e m was a periodic overhaul. I believed it was w o r t h s o m e t h i n g to a m a n : he w o u l d b e in a b e t t e r position to keep himself fit ; h e certainly w o u l d be in a b e t t e r position to get himself p u t right. W e selected P e e k h a m . ~Ve o p e n e d o u r show there. W e offered to every family a periodic o v e r h a u l for sixpence a week p e r family. I was n o t very astonished to get 200 to 300 families in a few m o n t h s . W e p u r s u e d t h a t e x p e r i m e n t - - w h i c h was a p u r e l y tentative e x p e r i m e n t - - f o r a b o u t t h r e e years. I t was n o t the sort of t h i n g t h a t we could expand. I t was a failure f r o m t h e p o i n t of view of the people. W e said to these people' " I f you come along we can spot y o u r disease earlier a n d send you to t h e medical m e n earlier." T h e y were n o t back for m o r e t h a n two or t h r e e m o n t h s before they n e e d e d f u r t h e r treatm e n t - - w e were j u s t repeating t h e old conditions. The syrnptomology m i g h t change f r o m one disease to a n o t h e r b u t you were still in a p r e t t y b a d position because you were r e t u r n ing the individual to his old e n v i r o n m e n t . F r o m t h a t p o i n t of view it was m o r e or less a failure. W e learned t h a t if we were going to do this t h i n g p r o p e r l y we m u s t provide a new a n d different e n v i r o n m e n t for t h e individuals t h a t we h a d p u t right t h r o u g h the medical services. T h e o t h e r fact we got o u t of it was t h a t m e n were anxious for information. T h e y would come into the s c h e m e a n d w o u l d p a y for it. T h e n Dr. Pearse a n d myself s p e n t seven years " in t h e wilderness " s t u d y i n g t h e data we h a d collected in t h e yearly overhauls m a d e d u r i n g t h e p r e v i o u s t h r e e years. Besides, I h a d to raise the m o n e y that was necessary to b u i l d t h e n e x t experimental cage in w h i c h I was going to p u t these h u m a n beings. T h e whole t h i n g was done o n a v o l u n t a r y basis. I do n o t t h i n k t h a t is necessarily a b a d t h i n g ; I t h i n k it is a good t h i n g t h a t we s h o u l d explain to t h e p h i l a n t h r o p i s t w h o has the m o n e y w h a t we are trying to do. O u r studies took us a very long way. I t was a scientific n e e d t h a t we s h o u l d work o n t h e " family " ; t h a t is n o t o u t of any s e n t i m e n t a l idea or f r o m t h e p o i n t of view of C h r i s t i a n morals. W e biologists s t u d y growth, a n d t h e processes of g r o w t h are two : one of t h e m w h i c h is exemplified b y t h e individual in t h e process of growing older a n d older ; a n d the o t h e r is j u s t as o b v i o u s n t h e process of growing younger, juvenescence, as essentially a n d f u n d a m e n t a l l y carried o n t h r o u g h t h e family. T h e family is t h e smallest u n i t o n w h i c h you can proceed o n biological lines. W e h a d to create this place as a family affair o u t of scientific necessity. T h e n we h a d to collect in o u r cage n o t j u s t a h a p h a z a r d sample of the population, b u t a sample of t h e p o p u l a t i o n w h i c h would r e p r e s e n t every h o m e f r o m w h i c h t h e y came i n action. W e n e e d a vertical section of society r e p r e s e n t i n g as far as possible every piece of genius of w h i c h t h e h u m a n b e i n g is capable. F o r instance, it is necessary to get a first-class footballer a n d in, say, D a g e n h a m it w o u l d take 10,000 families to provide two first-class footballers. W e w a n t e d to collect in o u r cage for experimental p u r p o s e samples of every one of these e x p o n e n t s w h e t h e r it was swimming, poetry, drama, etc. T h a t m e a n t a m o s t difficult p r o b l e m . W h a t was t h e smallest area in w h i c h we could collect t o g e t h e r a sample of all t h e h u m a n faculties in action ? W e set o u t to do a survey of L o n d o n in w h i c h I was assisted b y m a n y medical officers. W e f o u n d only two small nuclei w h e r e t h e r e were still families r a n g i n g f r o m 37s. 6d. a week u p to £2,000 to £3,000 a year. T h e s e were centred r o u n d t h e ancient village of F u l h a m a n d H a t c h a m (Peckham). W e chose P e e k h a m . W e explored t h e whole of the m e t r o p o l i t a n a r e a - - t h e o u t e r limit of L o n d o n seems to b e the radius of E p s o m . A t t h e extreme p e r i p h e r y * An address tO the County Borough M.O.H. Group, Society of Medical Officers of Health, Eastbourne, July, 1946.
OFFICER
OF H E A L T H *
By C. METCALFE BROWN, M.D., D.P.H., BARRISTER-AT-LAw,
Medical O~cer of Health, City of Manchester T h e unusual title of this address has been chosen for two reasons. First, it has a historical significance in that the appointment of the first Medical Officer of Health for Manchester was advertised as that of Officer of Health, the advertisement stating " that the Corporation were prepared to receive applications from gentlemen, whether medical or otherwise, who might be desirous of obtaining the appointment of Officer of Health for this city at a salary of £500 per annum." Mr. John Leigh, a Manchester surgeon, was appointed from a short list of four medical men, but amongst the other candidates were a colonel, a major, and a lieutenant of the British Army, all non-medical, two sanitary inspectors, a surveyor and a clergyman. T h e appointment was made in 1868, 21 years later than the appointment in Liverpool of the first Medical Officer of Health in this country--on the centenary of which we, as a Branch, will wish to accord our hearty congratulations .to the City of Liverpool and to celebrate in a manner fitting to the great occasion. T h e other reason for the choice of title is that it will serve to remind us that although it is vital that medical men, with adequate medical assistance, should be in charge of the public health departments, the bulk of the manifold duties are carried out, and in a highly efficient manner, by non-medical members of the staff, who are in truth officers of health working in conjunction with their medical colleagues. In this connection, I would commend the advantages of the appointment of lay administrative officers. Several public health departments have had these officers for many years and in Manchester, and no doubt elsewhere, the appointment has proved to be a happy and successful one, and has ensured a high standard of efficiency in administration and at the same time has relieved the medical staff of the unnecessary burden of many nonmedical matters. Public health officers, like the medical profession generally, and indeed other professions, find themselves this year at a crucial point as a result of the provisions of the National Health Service Bill. T h e last great change in public health administration following the Local Government Act, 1929, caused a vast addition to the responsibilities of departments, which has resulted in the occupation of at least half of the time of many medical officers of health in hospital administration. T h e new legislation bill do more than reverse the process for we lose the infectious diseases hospitals and the sanatoria that have been administered by medical officers of health, if not from time immemorial, at least before the commencement of the professional careers of most of the public health officers of to-day. These are serious losses, and yet I must confess that the transfer of the administration of the hospitals to regional hospital boards is sound policy, although one would be less than human if one did not have a pang of regret after years of experience of hospital administration under the aegis of local authorities. But it is not my purpose to discuss at length the many merits and the few possible demerits of the Bill. I propose to invite you to look forward rather than back, to consider the new duties and the changed duties and the new opportunities presented to us under the new regime. Hospitals It is inevitable that the transfer of hospital administration will mean also the transfer of many public health officers to the service of the regional hospital boards and, indeed, it is no exaggeration to say that the efficiency of the administration of these boards would be in grave jeopardy without the services of existing local authority officers possessing, as they do, wide experience in hospital matters. In the words of the Minister of Health at the annual luncheon of the Society of Medical Officers of Health in September, 1946, " It is our intention # Presidential Address to the North-Western Branch, Society of Medical Officers of Health, Manchester, October llth, 1946.
51 to try to use, so far as they will allow themselves to be used, all the vast body of health workers who have built up such a splendid tradition. We do not want to discard in any way the services of those who have accumulated so much experience." T h e staffs of voluntary hospitals will also no doubt be called upon to contribute their quota of the necessary staffs, and one may safely expect that the new staffs, composed of recruits from both types of hospital service, will together provide in time a high standard of service based on an unrivalled pool of variegated experience. Here, many will find the continuation of their life-work and many will find new and satisfying careers. T h e bulk of the present public health medical officers will remain in the public health departments, but although direct hospital administration will have gone there is no doubt that the spirit and intention of the Bill is to encourage the closest collaboration between the public health service and the new hospital service and indeed the most relevant criticism of the new Bill might be that having gone so far it might well have gone further and placed public health administration and other types of medical administration in the same hands as hospital administration and so have achieved unity of administrative control. T h e practical difficulties of such a course at the present time are easy to understand but it is to be hoped that the present step, admittedly a long one, is but the first of a series of steps towards the goal of a unified medical service. Sir Allen Daley has expressed the hope that the medical officer of health will continue to be associated with his hospital colleagues, for example, by membership of regional hospital boards and hospital management committees and collaborating in the development and maintenance of the hospital and specialist services. If that indeed comes to pass, then the medical officer of health will still be much occupied with hospital matters, although relieved of the detail of day-to-day administration. Child Health Servlees T h e Maternity and Child Welfare service and the School Health service together form the most important part of the work, present and future, of the public health officer, and although much has been done there is room and need for extension and improvement of our existing services. Who can say, for example, that the standard of school hygiene in his area is satisfactory ? In some areas it would be hard to find a single school which conformed to good standards. In this sphere alone there are boundless opportunities of using our influence for the sound planning of the many new schools to be erected and=we shall do well to remember that on the environmental side of our work, whilst the provision of new houses and the reconditioning of existing ones is the most urgent need, the need for decent and healthy school buildings is nearly as urgent and important. Lower in the priority list but still high up is the need for the suitable housing of the maternity and welfare service, and although we could all animadvert with good cause and some impatience on the inadequacy in q~ality and size of the welfare centres the new Act will provide an opportunity of experimenting with Health Centres, I hope, in conjunction with general practice. I trust, too, that the experimental period will not be too prolonged and that an increasing availability of labour and material will within a reasonable space of time give us premises worthy of their function in place of the many exasperating places that disgrace our service. But, just as in the history of medicine much pioneer research has been carried out with a minimum of equipment, so much good work goes on in spite of our disadvantages and important though the quality of premises may be, the quality of the staff is of much greater importance, and if that quality is to be maintained and improved an early rearrangement of the administrative structure is necessary. I believe that the right way lies in a fusion, nationally decreed, of the Maternity and Child Welfare Service and the School Health Service. T h e new legislation on Education and Health ensures that the two health services shall be administered by the same authority. It is becoming more and more difficult to discern the difference in function between a day nursery and a nursery school, and
PUBLIC HEALTH, December, 1946
52 the number of convalescent homes for children which become special schools overnight is increasing. These trends together are pointing the way--the way to a unified Child Welfare service--to the integration of the administratively disintegrated child. The various specialisms confined mainly to the child at school should be widened to include the child at home, at the welfare centre, and in hospital, and similarly the paediatrician in hospital and the welfare centre medical officer should be allowed to break their bonds and deal with the whole child, irrespective of age, condition or environment. A Chair of Child Health at the Regional University is an essential ingredient of this recipe and it is an encouraging sign of the willingness of local authorities to collaborate with each other that, at Manchester University, a Department of Child Healt~ is shortly to be inaugurated, supported financially not by Manchester alone, but by the major local authorities of the whole area to be served. The functions of the department should be advisory, teaching and research but not executive. On that basis the professor and his staff, which should include on a part-time basis several of the local authority officers now engaged on child health, should be certain of a welcome in all the child health sections o f the health departments, as well as those at present conducted by voluntary agencies. T h e beneficial effect of this democratic foundation will assuredly be that there will be a closer knitting together, not only of staffs and sections of the public health departments but of one department with another and of the public health service of the region as a whole with the children's hospitals under voluntary management. We have been later than other regions in achieving a Chair of Child Health, but it may well be that the unique combination of local authorities though somewhat slower in initial action, may prove to have found the most successful method of collaborating on child health with each other and with the university. In the same way as the medical officers, the health visitor and school nurse should merge their respective spheres and pursue their common aim together. Here again we should endeavour to be economical of specialist skill and use trained nursing personnel as far as possible for the duties of their profession and cover the other and equally important duties of the service by other specialists in increasing numbers--specialists trained in social science. And just as the duties of the medical officers of health evolved as medical sociology grew in importance and the original sanitary preoccupations passed to the care in general of the sanitary inspector, so the sanitary inspector is adding to his environmental duties increasing responsibilities in relation to the community as a social efitity--to the man as well as to his home and his workshop. And so we get the link between the health visitor and the social worker, and the link between the social worker and the sanitary worker, all working in conjunction with the clinician and the medical and non-medical administrator. This is a tidier picture than the present one, although we must avoid administrative tidiness for the sake of mere tidinessklet us strive for high ~fficiency tempered with humanity. Industrial Medicine
Our responsibilities already embrace the home environment, the welfare of the children and the domiciliary midwifery service and to these will shortly be added the duties of providing a service of home helps and of home nursing. Our responsibilities in the homes will be as important as they will be comprehensive. Similarly, we have responsibilities in relation to school hygiene in the workplaces of the children. But curiously, although we have some duties in relation to factories and workshops, the sphere of industrial medicine remains as a thing apart and the time is surely ripe for giving this important section of community service its rightful place in the public health scheme. Here is another step for the near future, a shorter and easier one than the long step we are about to take. Poor Law
It is likely that new legislation will shortly be introduced in relation to Poor Law, legislation which is long overdue, because
whilst it is true that there have been fairly recent Poor Law Acts, they have been consolidating rather than reforming and reform is urgently needed. How such new legislation will affect public health administration it is impossible to say but we shall no doubt inherit some of the estate of the dying administration. For many years in Manchester the administration of the main public assistance institutions has been delegated to the Public Health Committee, the masters of the institutions being responsible to the medical officer of health in the same way as the medical superintendents of the municipal hospitals. This system has worked with great smoothness and it is possible that it may be the forerunner of a national system. T h e care of aged persons, who represent an increasing proportion of our population, is so obviously a matter of welfare administration that the public health departments, with their increasing welfare trends, would appear to be the logical direction in which transfer should be made. Infectious D i s e a ~ s
Medical officers of health of both large and smaU areas could hardly do other than regret the departure of the isolation hospitals from their control, but, sorrowful though it may be, it is nevertheless logical that having decided on the principle of the removal of therapeutic services from the rest, the isolation hospitals should join company with all the other hospitals. Fortunately, the duties in relation to the prevention of infectious diseases and to epidemiology remain with us. I recall that when I was a medical student diphtheria immunisation was recognised as advantageous and reliable, yet after all these years we are now in the throes of trying to achieve a high percentage of immunised children and it is only within the last few years that an appreciable diminution of the number of deaths from diphtheria has occurred. It is a sad commentary on the inefficiency of health education in the past and of the difficulty of converting public opinion. Still, we are succeeding at last and a few more years of intensive effort should make diphtheria deaths as rare as scarlet fever deaths. Whooping cough immunisation would appear to be the next task and an interesting one it will be. Whooping cough is much more fatal than either measles or scarlet fever and the occurrence of this disease in a family is productive of much disorganisation and distress, leaving lifelong effects in many cases. American experiments with vaccines appear to have produced favourable results, but trials in this country have been inconclusive and the Ministry of Health is not yet, to quote the Chief Medical Officer, " sufficiently convinced of its value to justify a mass immunisation campaign." What are we to do ? Most of us probably feel that whooping cough prophylaxis is worth while and are prepared to advise a trial in individual cases, but in the light of the evidence and in particular of the opinion of the Ministry of Health, we may well hesitate to put the seal of approval on a method which may yet prove to be valueless although my own opinion~is that it will prove to be of value. Our clear duty, is to establish once and for all the efficiency of Whooping~cough prophylaxis and to that end the Medical Research Council, in conjunction with Manchester, Tottenham and Wembley, are commencing a trial which we hope may provide the answer. A quantity of Sauer's vaccine is to be made available in Manchester. Parents of infants are being asked to co-operate in this trial, which is explained frankly to them. The vaccine will be administered to half of these infants and the other half will get anti-catarrhal vaccine. All the children will be kept under close observation for a number of years and the incidence of whooping cough carefully noted. In order to eliminate psychological factors in estimating results, neither the parents nor the officers administering the vaccine will know whether a particular child has or has not received Sauer's vaccine and so a true scientific control will be achieved. If the results are what we hope they will be, the ultimate effect on the community will be inestimable. Here, then, is but one example of the type of work that lies before us all. T h e advent of chemotherapy has profoundly affected our therapeutic measures a n d the facility with which the synthetic chemist is able to modify drugs at will, and in predeter-
PUBLIC HEALTH, December, 1946 mined directions is a guarantee that the future will provide an ever-expanding armoury of new weapons. But these drugs are available for prevention as well as for cure, and Cruickshank's article on "Chemoprophylaxis in the control of bacterial infections," in the July issue of the Monthly Bulletin of the Ministry of Health and Public Health Laboratory Service, is invaluable not only as a summary of what has gone before and of how we can use the new knowledge, but also as an indication of the possibilities with regard to things to come, not as a cure-all in place of our present methods but ancillary to them. As Cruickshank says, " These drugs must not be used as a substitute for good hygiene." Recent years have witnessed the attainment of a high standard of efficiency of the Public Health Laboratory Service and progress is certain to continue. Collaboration between the scientists in the laboratory and the field workers in the public health departments is increasing and much excellent work has been carried out and fully reported, most of it capable of immediate practical application. Here lies an avenue of approach to our real work which many of us are already using and which all of us should use and with increasing frequency. T h e resultant team has unlimited opportunities before it, and there is much virgin soil to be ploughed. Environmental Conditions
T h e progressive improvement of basic environmental conditions has allowed us to turn our thoughts to matters which, given these conditions, were of even greater importance. But, the time has come when it might be well for us to give renewed attention to environment, not to detailed matters now delegated to sanitary inspectors but rather to questions of wide policy on a regional or national basis. We are all, unfortunately, only too acutely aware of the present grave position with regard to the high number of unfit houses in our respective areas and of the long period of years which must elapse before new housing overtakes the need. But the fact that millions of new houses are to be built does give us an opportunity of using our influence in the direction of better standards of house building and of fostering public opinion with regard to them. T h e need for smoke abatement is still as great as ever and the approach should be preventive in preference to therapeutic, although treatment will still be needed for a long time to come. We must make every effort, in conjunction with fuel and engineering experts, to determine the most efficient kind of apparatus for heating houses so that we may take advantage of the unprecedented opportunity presented to us by the building of the very large number of houses in years to come. T h e r e is no shortage of ideas--let us do our utmost to get them put into practice. Let us lend our aid to the engineers who are advocating district heating--the supply of warmth and constant hot water to houses from a central station--so that the standard of hygiene and comfort of these houses may be raised, that fuel may be used more efficiently and atmospheric pollution reduced.; Let us pursue the idea o f smokeless zones, let us recommend the use of smokeless fueLand,the iilspection and approval of industrial heating apparatus and the increased use of electricity and gas for heating and cooking. We may be sure of much support in these efforts by the National Smoke Abatement Society and the Regional .Smoke Abatement Committees of local authorities, a number of which are in active existence. Social and Emotional Factors
Much that I have already mentioned has loomed large in the professional thoughts of most of us and such action as has been open to us has been taken in many areas, although there is still much we can do. T h e wider problem of the ascertainment and remedy of psychological causes of ill health will form for many years one of the most important parts of our work. Fortunately, but only recently, the view has become widely held that physical ill health and psychological ill health are closely related and indeed are inseparable. For example, the so-called psychosomatic illnesses are creative of much distress and disability and require much consideration and
53 research. As field workers, we are in the best possible position to initiate and conduct such research. Similarly, the War has shown the extraordinary effect of a controlled and improved nutrition on the health of the community and we have a clear duty to support and foster every scheme which will assist in the maintenance and improvement of nutrition, for let us face the position quite frankly--most of our plans must come to nought in face of nutritional deficiency. Medical Statistics
It must be confessed that medical proficieney and statistical competence, except in a few outstanding cases, are rarely found in the medical profession. This undesirable state of affairs is not surprising in that the medical curriculum, quite properly, trains us as individualists with a humanistic outlook. T o attempt to train medical students as statisticians would inevitably embarrass either their medical or statistical studies or perhaps both. Medical graduates are normally fully occupied in hospital:, practice in their earlier years and in their later years are so much absorbed in their professional work that they are unable to spare the time to train in statistics. T h e only remedy would appear to be that those whose professional work does include statistics should spare some of their undoubtedly limited time to make themselves, if not expert statisticians, at least reasonably competent in statistical methods. Whether that may prove to be practicable or not, it would undoubtedly be advantageous if medical officers of health and their staffs did everything possible to raise the standard of statistical work in the public health departments. T h e need for such improvement is clear if we are to marshal effectively the facts so laboriously obtained in our work in research. T h e Monthly Bulletin is an invaluable ally in this direction, encouraging as it does co-operation between the departments and the laboratories, stimulating us and directing our attention to fresh fields and showing us by precept the best methods of investigation. I would go so far as to say that a set of the Monthly Bulletin is equal in importance, from our point of view, to any set of documents to be found in our departments. Those departments that possess a complete set of issues since they were first printed in November, 1941, are fortunate, wise and prudent, particularly in view of the fact that several of the earlier numbers are now unobtainable. It behoves us, therefore, to cherish the copies we possess and, in cherishing them, to consult them frequently. Health Education
As health officers we are leaders in the task of educating the public in health matters but if a leader is too far ahead of his company his leadership is just as ineffective as the type of leadership shown by the Duke of Plaza-Toro : - " He led his regiment from b e h i n d - H e found it less exciting." In other words, we must not get too far ahead of public opinion, although we should always be in front of it. Fortunately, modern methods of publicity will tend to facilitate our work in this respect, and the following are some of the most promising methods : - (1) T h e fullest co-operation with the Central Council for Health Education and their officers. T h e propaganda material issued by the Council is excellent in quality and quantity, and if there is any defect in the present arrangements it is that the distribution of this excellent material is not sufficiently wide. We are all doing our best to distribute the Council's publications within our own service and to some extent beyond it, but means should be devised for ensuring its penetration far beyond existing circulations. This means not only persistent efforts on the part of officers but increased financial support of the Council by the local authorities. (2) T h e increasing use of newspaper advertisements and articles. As newsprint becomes more and more available our opportunities will increase correspondingly. (3) T h e u s e of xadio propaganda by officers of the Ministry of Health and of representatives of local authorities. (4) Loud speaker vans for making announcements and
PUBLIC HEALTH, December, 1945
54 applying persuasion at the very h o m e s of the people. T h i s is particularly useful in t h e c o n d u c t of campaigns s u c h as t h a t for d i p h t h e r i a i m m u n i s a t i o n . (5) T h e use of posters a n d bills on p u b l i c t r a n s p o r t vehicles w h e r e the m a n a g e r s of t r a n s p o r t u n d e r t a k i n g s can b e persuaded to p e r m i t t h e m . (6) T h e increasing film-going t e n d e n c i e s of the general p u b l i c give us an o p p o r t u n i t y of a p p r o a c h i n g t h e m and ensuring t h a t o u r publicity will reach t h e m . T h e m e t h o d is expensive a n d b y n o m e a n s easy b u t t h e chances of successful appeal to p u b l i c opinion are u n d o u b t e d l y high. I k n o w it is easy to advocate these m e t h o d s b u t difficult to apply t h e m , b u t we h a v e k n o w n difficulties before and have successfully o v e r c o m e t h e m . Teaching T h e N a t i o n a l H e a l t h Service Act will b r i n g to t h e hospital service t h e valued interest a n d co-operation of t h e universities as n e v e r before a n d a corresponding interest of t h e universities in t h e practical work of the o t h e r medical services would b e equally welcome. T h i s spirit of co-operation can b e fostered b y willingness to teach university s t u d e n t s a n d m a n y of the public health d e p a r t m e n t s are already taking an eager and i m p o r t a n t p a r t in this excellent work. O n e hesitates to ask already o v e r b u r d e n e d staffs to u n d e r t a k e these t i m e - c o n s u m i n g duties b u t t h e rewards are great. W e have t h e satisfaction of helping to t r a i n the intellectual workers of t h e f u t u r e and at t h e same time to reap great advantages as a result of t h e stimulation t h a t teaching gives to the teacher. I n conclusion, t h e r e are some w h o fear as a result of the great t r a n s f e r of work a b o u t to take place t h a t t h e p u b l i c h e a l t h d e p a r t m e n t s will d i m i n i s h in influence, size a n d importance. I h o p e I have h e l p e d to d e m o n s t r a t e t h a t o n the contrary t h e future holds for us actual work a n d potential work of greater i m p o r t a n c e even t h a n o u r work of t h e present, t h e d e p a r t m e n t s will increase r a t h e r t h a n decrease a n d for those w h o have t h e will, the energy a n d t h e r i g h t outlook, there are b o u n d l e s s o p p o r t u n i t i e s of satisfying service in t h e years t h a t lie before us.
THE U N P R O T E C T E D TRAVELLER, OR, T H E RISKS OF GOING TO WORK I take this opportunity of quoting a paragraph which appeared in my Annual Report for the year 1930:-" Inasmuch as a very large proportion of the inhabitants work in the City and County of London, it is aptly described as a ' dormitory of the Metropolis.' By no stretch of the imagination can it be claimed that Leyton is well served as regards facilities for travelling by rail, and the extent of the overcrowding in the trains to and from London during ' r u s h h o u r s ' cannot be regarded as other than a potent factor in the spread of communicable disease. Your Council has wisely made representations to the Railway Company with a view to the provision of better facilities for the travelling public, but apparently without avail. The conditions under which our City workers earn their living are often far from ideal as regards light, ventilation, noise, overcrowdPag, etc. Although ~ Health Authorities and the Home Office possess statutory powers tor controlling the conditions of work in factories and workshops, no such powers exist for the protection of the great body of clerical workers, etc., in the offices of the City. ' The tired City-worker' is an expression in everyday use, and there can be little doubt that the conditions of work in the City---coupled with the nervous strain associated with journeys to and from work--play a considerable part in the production of that ' tired' feeling. All City workers may not return from work bodily tired, but all tired City workers return with diminished bodily resistance against infection; and it is in this state of impaired resistance that they are compelled to run the gauntlet of massive doses of infection in dirty, stuffy and overcrowded railway compartments." Not only has there been no improvement since that time, but there has been a marked deterioration in the appalling conditions under which Leyton residents have had to travel to and from London during and since the war. I have always considered that overcrowded public transport vehicles were the most fruitful source of respiratory infection; and, until such time as travelling conditions are rendered less dangerous, there is much to be said in favour of the continuatioo of the war-time poster " I s your journey really necessary? "--Dr. ANnREw FoaaEsr (M.O.H., Leyton M.B.) in his Annual Health Report for 1945.
THE
PECKHAM
PIONEER
HEALTH
CENTRE*
By G . SCOTT WILLIAMSON, M.C., M.D., CH.B., L.R.C.P., L.R.C.S., ED., Medical Director, The Pioneer Health Centre, Pechham M y collaborators a n d I, after some years of work on colonies of rats, realised t h a t we could n o t p u r s u e o u r e x p e r i m e n t s o n animals any further. H o w on e a r t h were we going to get h u m a n beings to come into contact w i t h scientists ? All we h a d to sell t h e m was a periodic overhaul. I believed it was w o r t h s o m e t h i n g to a m a n : he w o u l d b e in a b e t t e r position to keep himself fit ; h e certainly w o u l d be in a b e t t e r position to get himself p u t right. W e selected P e e k h a m . ~Ve o p e n e d o u r show there. W e offered to every family a periodic o v e r h a u l for sixpence a week p e r family. I was n o t very astonished to get 200 to 300 families in a few m o n t h s . W e p u r s u e d t h a t e x p e r i m e n t - - w h i c h was a p u r e l y tentative e x p e r i m e n t - - f o r a b o u t t h r e e years. I t was n o t the sort of t h i n g t h a t we could expand. I t was a failure f r o m t h e p o i n t of view of the people. W e said to these people' " I f you come along we can spot y o u r disease earlier a n d send you to t h e medical m e n earlier." T h e y were n o t back for m o r e t h a n two or t h r e e m o n t h s before they n e e d e d f u r t h e r treatm e n t - - w e were j u s t repeating t h e old conditions. The syrnptomology m i g h t change f r o m one disease to a n o t h e r b u t you were still in a p r e t t y b a d position because you were r e t u r n ing the individual to his old e n v i r o n m e n t . F r o m t h a t p o i n t of view it was m o r e or less a failure. W e learned t h a t if we were going to do this t h i n g p r o p e r l y we m u s t provide a new a n d different e n v i r o n m e n t for t h e individuals t h a t we h a d p u t right t h r o u g h the medical services. T h e o t h e r fact we got o u t of it was t h a t m e n were anxious for information. T h e y would come into the s c h e m e a n d w o u l d p a y for it. T h e n Dr. Pearse a n d myself s p e n t seven years " in t h e wilderness " s t u d y i n g t h e data we h a d collected in t h e yearly overhauls m a d e d u r i n g t h e p r e v i o u s t h r e e years. Besides, I h a d to raise the m o n e y that was necessary to b u i l d t h e n e x t experimental cage in w h i c h I was going to p u t these h u m a n beings. T h e whole t h i n g was done o n a v o l u n t a r y basis. I do n o t t h i n k t h a t is necessarily a b a d t h i n g ; I t h i n k it is a good t h i n g t h a t we s h o u l d explain to t h e p h i l a n t h r o p i s t w h o has the m o n e y w h a t we are trying to do. O u r studies took us a very long way. I t was a scientific n e e d t h a t we s h o u l d work o n t h e " family " ; t h a t is n o t o u t of any s e n t i m e n t a l idea or f r o m t h e p o i n t of view of C h r i s t i a n morals. W e biologists s t u d y growth, a n d t h e processes of g r o w t h are two : one of t h e m w h i c h is exemplified b y t h e individual in t h e process of growing older a n d older ; a n d the o t h e r is j u s t as o b v i o u s n t h e process of growing younger, juvenescence, as essentially a n d f u n d a m e n t a l l y carried o n t h r o u g h t h e family. T h e family is t h e smallest u n i t o n w h i c h you can proceed o n biological lines. W e h a d to create this place as a family affair o u t of scientific necessity. T h e n we h a d to collect in o u r cage n o t j u s t a h a p h a z a r d sample of the population, b u t a sample of t h e p o p u l a t i o n w h i c h would r e p r e s e n t every h o m e f r o m w h i c h t h e y came i n action. W e n e e d a vertical section of society r e p r e s e n t i n g as far as possible every piece of genius of w h i c h t h e h u m a n b e i n g is capable. F o r instance, it is necessary to get a first-class footballer a n d in, say, D a g e n h a m it w o u l d take 10,000 families to provide two first-class footballers. W e w a n t e d to collect in o u r cage for experimental p u r p o s e samples of every one of these e x p o n e n t s w h e t h e r it was swimming, poetry, drama, etc. T h a t m e a n t a m o s t difficult p r o b l e m . W h a t was t h e smallest area in w h i c h we could collect t o g e t h e r a sample of all t h e h u m a n faculties in action ? W e set o u t to do a survey of L o n d o n in w h i c h I was assisted b y m a n y medical officers. W e f o u n d only two small nuclei w h e r e t h e r e were still families r a n g i n g f r o m 37s. 6d. a week u p to £2,000 to £3,000 a year. T h e s e were centred r o u n d t h e ancient village of F u l h a m a n d H a t c h a m (Peckham). W e chose P e e k h a m . W e explored t h e whole of the m e t r o p o l i t a n a r e a - - t h e o u t e r limit of L o n d o n seems to b e the radius of E p s o m . A t t h e extreme p e r i p h e r y * An address tO the County Borough M.O.H. Group, Society of Medical Officers of Health, Eastbourne, July, 1946.