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The public health administrative unit
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PUBLIC HEALTH.
THE PUBLIC HEALTH ADMINISTRATIVE UNIT.* BY A. ANDERSON, M.A., M.B., D.P.H., Medical Officer of Health, Wortley Rural District. S year is a T H Ithe medical
critical one in the history of profession, and the public health service cannot fail to be affected by the profound movement that is taking place in the relations of the profession to the State. The medical profession has at last been caught in the whirlpool of social unrest, and, whatever solution of the existing difficulties attending service under the Insurance Act may be arrived at, things can never be as they were in the medical world. The State, which has hitherto concerned itself mainly with measures for the prevention of disease, is now in various ways embracing within its purview the treatment of disease as well. This extension of State supervision must ultimately have the effect of m a k i n g every practitioner, directly or indirectly, a worker in the cause of public health, for the protection of the health of the community is intimately bound up with the preservation of the health of its individualcitizens. In this sense preventive medicine may be said to be coming into its own, and taking its rightful place in the general scheme of things. The arbitrary division of medicine into a preventive branch on the one hand and a curative branch on the other hand is much to be deprecated. There is no antagonism, rightly considered, between preventive and curative medicine, any more than there is between lJublic and private work, or between eugenics and hygienics. It is only the manner in which medical practice has grown up that has given a semblance of conflicting interests and intentions. To reconcile the interests, to harmonise the motives, and to unite the energies of medical men is not impossible. But it will require large views of the whole problem on the part ef the profession and the public, and wise guidance on the part of our Statesmen. The opportunity has, I think, now arrived for the evolution of a national scheme of unification and co-ordination of all forms of medical work and endeavour, which, while being of inestimable value in promoting the public welfare, will not be detrimental to, nor will alienate the sympathies of, the profession as a whole. Such a scheme cannot, however, be evolved at a moment's notice. A process of hustle will not do. Hurried legislation and Presidential Address read before the Yorkshire Branch at the meeting of December iSth, i9~2.
FEBRUARY,
journalese thinking are our fashionable legal and literary vices, and they are both unhygienic. Like bolted meals, they cause bad attacks of dyspepsia in the community. Our laws are no sooner made t h a n they are amended; our dogmas are no sooner uttered than they are exploded. W e are rushing for the millennium of national well-being, and we have no time for masticating, still less digesting, our legal and scientific meals. W e are attracted by the fare provided; we glory in our legislative output, we hug our medical catchwords. The consequence is that we pass by the simple doctrines that want proving and the small legislative measures that ought to be placed on the Statute Book. W e have had recently a surfeit of intricate and badly worded enactments, but we have not yet had, for example, any proper definition of a drain or a sewer. So in the realm of administration, the obvious defects have received little or no attention. But they are none the less important, and cannot any longer be ignored. While, then, schemes are in the air for a State Medical Service, while all our old institutions are in the melting-pot, while Boards of Guardians are on the way to abolition ana our general hospitals are in danger of being nationalised, there is one aspect of this revolutionary movement which has, curiously enough, been almost lost sight of, but which is of the first importance, namely, the need for abolishing the sanitary unit as it exists to-day, and for revising and improving the conditions of the public health service, especiat!y in rural and small urban areas, Our own household must, first of all, be put in order. Now, in considering this question, it should be borne in mind that the health of the nation never has been a matter of other than national concern, and it is in these modern days less a local matter t h a n ever. The increasing urbanisation of the population, the vastly improved means of inter-communication between one place and another, the increase in our over-sea trade, have, amongst other things, bad the effect of making the sanitary conditions and administration of any particular district as much a matter of national as of local importance. The lax administration of any sanitary unit may be reflected in the whole country in a disastrous manner. The medical attitude to disease, too, is different. It is no longer a question mainly of environment, of drainage and other nuisances, but of the movements and carrying powers, of
1913.
PUBLIC HEALTH.
the habits and predispositions of perscns. Whatever may be the true relation between environment and hereditary equipment, there is no doubt that the influence of environment is becoming less important as a factor determining the health of the individuali It is quite true that progress in the past has been due mainly to the effect of improved environment, to indirect measures against disease. Very little has so far been accomplished by direct measures. Hunting the microbe or the person who harbours the microbe is a fascinating sport, b u t the kills are few and far between. Yet there is a limit to the effect of improved environment, and it must be admitted that in not a few districts--though, unfortunately, this cannot be said of the West Riding-there is comparatively little that remains to be done by way of improving the external conditions under which people live. The work of the medical officer of health is, therefore, now more a personal matter, directed to the investigation of individual weaknesses and signs of potential ill-health, to detecting disease in its very earliest stages, to the searching for healthy infection-carrying individuals, and to the regulation of their habits. Public health is thus b~coming more and more a matter that does not concern a local body as such. And it is difficult to see why, in all those questions that are of importance from a public health standpoint, small local bodies should have any judicial powers whatever. Much criticism could not, however, be directed against the present system if the local authorities had proved themselves efficient and had competently carried out the duties assigned to them. Some people--such as the signatories of the Minority Report--talk as if the existing system of public health administration was all that could be desired, and they hold it up as a model to be copied. But they have surely made the mistake of confusing sanitary authorities with county councils, who are not sanitary authorities, but have had certain sanitary work thrust on them. Boards of guardians have recently been subjected to much criticism because they have not carried out their duties properly, and have failed to adapt themselves to modern ideas and conditions; but, surely, a much stronger indictment could be brought against sanitary authorities ? Within the limits of their legislative powers boards of guardians have, I think, carried out their work much more carefully and efficiently than have district councils,
127
and this is the opinion of members who serve on both bodies at the same time. This is due partly to the fact that boards of guardians cannot move a step without being confronted with some definite Order or Regulation of the Local Government Board, and partly to the nature of their work, which does not give rise to so much personal feeling and prejudice. They are also subject to a much more careflfl and detailed inspection by the Government inspectors. This, no doubt, has its disadvantages, and has in some respects hampered t h e more far-seeing and enterprising boards; but from the point of view of efficiency the abolition of boards of guardians is not by any means so urgently demanded as the abolition of our rflral and smaller urban district councils. These bodies have been weighed in the balance, and found wanting. T h e y have, time and again, been pilloried by the Local Government Board for gross neglect and default; they have lately been subjected to the satiric shafts of the Chancellor of the Exchequer; yet they are still alive, and have even escaped the attentions of a Royal Commission. One would have thought that the numerous instances of default on the part of district councils that have been brought to light by the inspectors of the Local Government Board would have compelled our legislators to have devised long ago some effective remedy. But, apart from advice, ineffective threats, and the insertion of defaulting clauses in recent Acts, nothing of any consequence has been done. The latest attempt appears in the Insurance Act, where the inept, but truly British, method is sanctioned of giving power to still another authority to fine the sanitary authorities for excessive amounts of sickness in their areas. This is going one better than the clause in the Housing and Town Planning Act, where the servant of one authority is penalised for not giving information gratuitously to the servant of another authority. T o what a pass has local government arrived in this country ! There are many other disadvantages attaching to the present system. One is that the existing sanitary areas are far too small for modern administrative purposes, and they are not in anyway related to the areas of Poor Law unions or registration districts. Nor, as a rule, are their boundaries marked out with any scientific regard to watershed and drainage areas. Hence there is both statistical and engineering confusion. BI
128
PUBLIC
A striking illustration of unscientific boundarymaking came under my notice in connection w i t h the recent extension of a large city. At one place the new boundary line was drawn along one side, not in the middle, of a main road, so that the whole of that part of the road has to be maintained by the district council. The levels were such that the drainage of new houses built on the district side of the road had no outlet except into the city sewer; but, worse than that, the drainage of some of the houses built on the city side of the road could not possibly get into the city sewer. That results from tracing the boundary line on a map without sufficient study of the contour lines or inspection of the locality. There is also quite an unnecessary amount of overlapping in the work of local authorities. Instead of improving, it is getting worse. There are, for example, in many districts .whole-time school medical officers traversing in some instances the same areas as the local medical officers of health, both going into the same schools, sometimes for the same, more often for a different, purpose. There is supposed to be co-operation between them; but is not this co-operation more a figment of the official imagination than anything else ? The administration of sanatorium benefit will cause further overlapping, and tile Milk Bill will probably have the same effect. Then there are health visitors appointed by district councils, school nurses appointed by county councils, lady visitors appointed by boards of guardians to visit the homes of boarded-out children and the children of parents in receipt of relief, all going over the same ground, and lady tuberculosis visitors will no doubt shortly be treading on their heels. School attendance officers and relieving officers together obtain valuable information regarding the bulk of the industrial population" which would be most useful to sanitary authorities, and would be available if there were any sort of co-ordination of local work. Another disadvantage of the present system is the want of uniformity of sanitary administration in adjoining districts and the impossibility of attaining it. Is it right, for example, that cowkeepers in one district should be under a more or less rigid system of veterinary inspection while those in an adjoining district are free from inspection altogether ? Again, does anyone think it likely that town-planning will proceed apace in the W e s t Riding with its I59 sanitary districts ?
HEALTH.
FEm~UAI~V,
I need not say much regarding the anomalous position of the medical officer of health, who has, in effect, to criticise his own master, and report on his shortcomings to two or three higher authorities, and who has constantly to inspect, and report on defects on the property of members of the authority that employs him. Even if he had satisfactory tenure of office and were adequately paid, he could not h a y e a peaceful life while such a Gilbertian state of things existed. Is there any other official in the kingdom who is placed in such an extraordinary position ? Imagine the chaos that would result in the administration of the Factory Acts if the inspectors were employed and paid, in whole or in part, by the owners of the factories. The marvel to me is not that there is occasional friction between the official and his authority, but that it is not all friction. W e are trulya phlegmaticrace to have tolerated such a tragi-comic arrangement so long. Looking then to the past and still more to the future, I think that a radical change in the constitution of local health authorities and in the conditions of the public health service, at all events in county areas, is urgently demanded. It is not, perhaps, easy to find a simple scheme of reconstruction. So many local and personal interests are involved and such a fetish is now made of local government that it will be difficult to stay the hybrid monster. Some find a remedy in the creation of a Government Health Department with a responsible Mimster of Health at its head, Personally, I am not one of those enthusiasts who think progress is necessarily made by a mere change in nomenclature. So tong as local authorities remain as they are it will not make much difference whether the Right Hon. John Burns is designated President of the Local Government Board or Minister of Health. That seems to me to be beginning at the wrong end. It is the local, not the central, body that has to be strengthened and endowed with greater dignity. If, then, the local authorities are so weak and untrustworthy that no Government thinks of entrusting them with the administration of any new important departure in public health legislation, the powers that be should see to it that their multiplication is not sanctioned without the most cogent reasons being forthcoming. But, unfortunately, small urban districts are frequently being formed on some pretence of a hypothetical betterment in local government which rarely ensues. Dr. Newsholme,
1913.
PUBLIC ~EALTH.
speaking of inefficient units of administration, says *that " some of the most flagrant examples are to be found in the West Riding, in which inefficient urban districts have been formed under the powers given to the County Council by the Local Government Act, I888, which enabled them to carve urban districts out of rural districts within the administrative county, the Local Government Board having no power to prevent the formation of these inefficient districts unless the rural or urban distrfcts concerned opposed the proposed action and appealed to the Board. At the same time, very little action has been taken by this and other county councils to act on their powers to form more satisfactory units for local government when the present units were obviously inefficient and extravagant." The county c o u n c i l s have, therefore, in this respect failed to rise to the modern occasion, and have adopted the retrograde course of splitting up, instead of amalgamating, areas. The policy of amalgamation has a good deal to be said in its favour. It has been successful in the case of the Pottery Towns, and what does the extension of large cities mean but the amalgamation of the city with the surrounding urban or rural areas. The objection which is commonly raised to the' formation of large sanitary units, which include urban as well as rural localities, is the difficulty of equable rating; but this is largely of the nature of a bogey, for there appears to be ample power in the Public Health Acts of forming special districts within that area for the particular purpose required. The fact is also overlooked that many of our large towns now includewithin their boundaries considerable rural areas, and nothing is ever heard after a few years of anomalies of rating. Sanitary districts might be amalgamated straightway without losing any of their powers, or they might be combined for the purpose of carrying out all their duties that are of sanitary import, leaving their other functions intact, such as the maintenance of district roads, the pro~'ision of recreation grounds, public libraries, museums, baths, etc. The best scheme, perhaps, would be to remove all their sanitary duties from existing councils, and to throw them on the county council. It is, of course, indefdnsible that there should be two authorities in the s a m e area, each with sanitary powers limited in one or another direction. The evolution of local government has, moreover, tended to concentrate all really important matters in the county * PUBLIG }~rI~ALTH, A u g u s t ,
1909.
129
council. This development seems to be, on the whole, on right lines. I do not say that county councils are above criticism, I do not admire some of their methods an 3' more than I respect some of their motives. But the larger the body the less parochial it tends to be, and the tess chance is there of petty personal interests predominating to the detriment of the public weal. Such a system has worked well in Scotland. In England some of the counties have become so populous and the work thrown on the county councils has so increased of late years that few men can be found with the necessary leisure for committee work, and the real power in consequence rests in the hands of a few men. In this sense the county council is not a truly democratic body; but so far as health matters are concerned it is none the worse for that. This difficulty could be easily surmounted by dividing the county into wards or districts, each district being administered by a district committee, on whom the necessary powers would be conferred. The unification of all sanitary and related sanitary work could then easily be attained. Other methods of solving the problem seem to me to be either partial in their remedial value or impracticable. Some good would undoubtedly be accomplished in the way of stimulating local authorities if, after the manner of the Housing Regulations, definite regulations were drawn up by the Local Government Board, and enforced in regard to other branches of public health work. Government by regulation has its advantages. The Housing Regulations have given a greater impetus to the systematic inspection of, and the carrying out of structural improvements in, dwelling-houses than all the Housing Acts put together. An extension of this principle would be useful, though it would not promote the unification of areas and offices, which is so desirable. The giving of Government grants to local authorities as a bonus for efficient administration and as an aid in the provision of works of sewage, or water supply, or in the erection of working.class dwellings in small localities, where the expense of providing these is out of all proportion to the rateable value, would also be beneficial; but these could be granted equally to the larger as to the smaller units. The combination of districts for the purpose of appointing a whole-time medical officer of health is good so far as it goes ; but it does not go very far so long as the existing sanitary units remain.
180
PUBLIC HEALTH.
The ideal, so far as the medical officer of health is concerned, would be the establishment of a real State health service, the medical officers being appointed and paid by, and responsible only to, the State, as the factory inspectors are. This may sound somewhat Utopian, but I see no inherent difficulty in an arrangement of this sort. If no alteration were contemplated in the existing authorities it would be far better than any security of tenure of office. This has to some extent improved,but is not yet entirely satisfactory. Dr. Newsholme thinks that "efficient sanitary administration demands the extension of satisfactory conditions of tenure of office " - - a n d I should add, the superannuation of sanitary officers--" and the most satisfactory settlement of the problem will come in connection with the establisbment of efficient units of local government." The time is now, I think, ripe for a solution of this administrative problem. Preventive medicine has been placed on a high pedestal, and we cannot allow any part of the masonry to be defective or insecure. CITY OF NOTTINGHAM.--Dr. Boobbyer's report for I9II is specially noteworthy for the amount of detail given and analysis carried out in connection with the various causes of death. A considerable increase in the number of deaths from cancer is noted, and on the question of the relation of improved diagnosis to this Dr. Boobbyer points out that the deaths ascribed to cancer of the skin, respecting tbe diagnosis--of which there is not likely to have been at any time much difficulty or doubt--have remained singularly uniform in number year after year. Diarrhoea, enteric fever, and tuberculosis are all very fully considered. In connection with enteric considerable improvements are noted, which are ascribed to the fact that pail-closets are rapidly disappearing, and water-closets taking their place. In the appendix an exceedingly interesting special report on pail-closets is reprinted, and in the introductory letter it is noted that the council have arranged to assist owners to bear the cost of conversion of such closets into water-closets. Other special reports reproduced relate to tuberculosis, and deal with sanatorium benefi~ and the tuberculosis dispensary. The percentage of births notified under the Notification of Births Act was 68.2. Up to the present persons failing to notify have not been prosecuted. Dr. Boobbyer, however, considers that the time for bringing legal pressure to bear has arrived. The inspectorial staff, though apparch tly small, accoun ted for a considerable amo tint of work and great improvements, especially in the matter of housing, are looked for in the future.
FEBRUARY,
THE TREATMENT OF SCARLET FEVER BY S T R E P T O C O C C A L VACCINES. ~ By NORMAN H. WALKER, M.B., B.S., London, M.R.C.S., L.R.C.P., D.P.H., Late Assistant M.O.H., Willesden, and Deputy Medical Superintendent, Willesden Isolation Hospital. Fever problem is one that may T H Ebe Scarlet looked at from many points of view, and these vary according to the particular branch of the medical profession in which the observer is engaged. Of the many difficulties encountered, that of diagnosis is perhaps the most common. Anyone who has had to make a definite diagnosis in cases of doubtful scarlet fever on the first occasion of seeing them, whether he be general practitioner, medical officer of health, or superintendent of an isolation hospital, must at times have felt the want of some positive test for the disease. Similarly all will agree, I think, that we badly require some reliable means of judging when a case is no longer infectious. At the present time, ira case of the disease gives rise to a " r e t u r n " case either of the " h o s p i t a l " or " h o m e " denomination, the primary case is known to be still infectious or to have developed a recrudescence of infectiousness--a not uncommon occurrence, as Dr. Butler, of Willesden, has pointed out. This, as a test for infectiousness, is positive but extremdy unfortunate when verified. In the case of diphtheria the bacteriological examination enables one to make a certain diagnosis in doubtful cases, and aids One to decide when isolation is no longer necessary. W h e n the causal organism of scarlet fever is certainly discovered, similar help should be forthcoming in the case of the latter. The immense amount of research work that has already been undertaken on the bacteriology of this disease has, I think, left many unconvinced that the Streptococcus Scartatin~e of Dts. Klein and Gordon or the Streptococcus Conglomeratus of Kurth is really the causal organism. Since the Hendon outbreak in I885, when Dr. Klein isolated streptococci from the blood during life in four out of eight cases examined by him, which organisms he identified with those obtained from lesions on the udders of the cows, numerous attempts have been made to bring in a verdict of guilty against one *A paper read at a meeting of the H o m e
Counties Branch of the
So~;iety of ModiGal Officers of Health.
PUBLIC HEALTH.
THE PUBLIC HEALTH ADMINISTRATIVE UNIT.* BY A. ANDERSON, M.A., M.B., D.P.H., Medical Officer of Health, Wortley Rural District. S year is a T H Ithe medical
critical one in the history of profession, and the public health service cannot fail to be affected by the profound movement that is taking place in the relations of the profession to the State. The medical profession has at last been caught in the whirlpool of social unrest, and, whatever solution of the existing difficulties attending service under the Insurance Act may be arrived at, things can never be as they were in the medical world. The State, which has hitherto concerned itself mainly with measures for the prevention of disease, is now in various ways embracing within its purview the treatment of disease as well. This extension of State supervision must ultimately have the effect of m a k i n g every practitioner, directly or indirectly, a worker in the cause of public health, for the protection of the health of the community is intimately bound up with the preservation of the health of its individualcitizens. In this sense preventive medicine may be said to be coming into its own, and taking its rightful place in the general scheme of things. The arbitrary division of medicine into a preventive branch on the one hand and a curative branch on the other hand is much to be deprecated. There is no antagonism, rightly considered, between preventive and curative medicine, any more than there is between lJublic and private work, or between eugenics and hygienics. It is only the manner in which medical practice has grown up that has given a semblance of conflicting interests and intentions. To reconcile the interests, to harmonise the motives, and to unite the energies of medical men is not impossible. But it will require large views of the whole problem on the part ef the profession and the public, and wise guidance on the part of our Statesmen. The opportunity has, I think, now arrived for the evolution of a national scheme of unification and co-ordination of all forms of medical work and endeavour, which, while being of inestimable value in promoting the public welfare, will not be detrimental to, nor will alienate the sympathies of, the profession as a whole. Such a scheme cannot, however, be evolved at a moment's notice. A process of hustle will not do. Hurried legislation and Presidential Address read before the Yorkshire Branch at the meeting of December iSth, i9~2.
FEBRUARY,
journalese thinking are our fashionable legal and literary vices, and they are both unhygienic. Like bolted meals, they cause bad attacks of dyspepsia in the community. Our laws are no sooner made t h a n they are amended; our dogmas are no sooner uttered than they are exploded. W e are rushing for the millennium of national well-being, and we have no time for masticating, still less digesting, our legal and scientific meals. W e are attracted by the fare provided; we glory in our legislative output, we hug our medical catchwords. The consequence is that we pass by the simple doctrines that want proving and the small legislative measures that ought to be placed on the Statute Book. W e have had recently a surfeit of intricate and badly worded enactments, but we have not yet had, for example, any proper definition of a drain or a sewer. So in the realm of administration, the obvious defects have received little or no attention. But they are none the less important, and cannot any longer be ignored. While, then, schemes are in the air for a State Medical Service, while all our old institutions are in the melting-pot, while Boards of Guardians are on the way to abolition ana our general hospitals are in danger of being nationalised, there is one aspect of this revolutionary movement which has, curiously enough, been almost lost sight of, but which is of the first importance, namely, the need for abolishing the sanitary unit as it exists to-day, and for revising and improving the conditions of the public health service, especiat!y in rural and small urban areas, Our own household must, first of all, be put in order. Now, in considering this question, it should be borne in mind that the health of the nation never has been a matter of other than national concern, and it is in these modern days less a local matter t h a n ever. The increasing urbanisation of the population, the vastly improved means of inter-communication between one place and another, the increase in our over-sea trade, have, amongst other things, bad the effect of making the sanitary conditions and administration of any particular district as much a matter of national as of local importance. The lax administration of any sanitary unit may be reflected in the whole country in a disastrous manner. The medical attitude to disease, too, is different. It is no longer a question mainly of environment, of drainage and other nuisances, but of the movements and carrying powers, of
1913.
PUBLIC HEALTH.
the habits and predispositions of perscns. Whatever may be the true relation between environment and hereditary equipment, there is no doubt that the influence of environment is becoming less important as a factor determining the health of the individuali It is quite true that progress in the past has been due mainly to the effect of improved environment, to indirect measures against disease. Very little has so far been accomplished by direct measures. Hunting the microbe or the person who harbours the microbe is a fascinating sport, b u t the kills are few and far between. Yet there is a limit to the effect of improved environment, and it must be admitted that in not a few districts--though, unfortunately, this cannot be said of the West Riding-there is comparatively little that remains to be done by way of improving the external conditions under which people live. The work of the medical officer of health is, therefore, now more a personal matter, directed to the investigation of individual weaknesses and signs of potential ill-health, to detecting disease in its very earliest stages, to the searching for healthy infection-carrying individuals, and to the regulation of their habits. Public health is thus b~coming more and more a matter that does not concern a local body as such. And it is difficult to see why, in all those questions that are of importance from a public health standpoint, small local bodies should have any judicial powers whatever. Much criticism could not, however, be directed against the present system if the local authorities had proved themselves efficient and had competently carried out the duties assigned to them. Some people--such as the signatories of the Minority Report--talk as if the existing system of public health administration was all that could be desired, and they hold it up as a model to be copied. But they have surely made the mistake of confusing sanitary authorities with county councils, who are not sanitary authorities, but have had certain sanitary work thrust on them. Boards of guardians have recently been subjected to much criticism because they have not carried out their duties properly, and have failed to adapt themselves to modern ideas and conditions; but, surely, a much stronger indictment could be brought against sanitary authorities ? Within the limits of their legislative powers boards of guardians have, I think, carried out their work much more carefully and efficiently than have district councils,
127
and this is the opinion of members who serve on both bodies at the same time. This is due partly to the fact that boards of guardians cannot move a step without being confronted with some definite Order or Regulation of the Local Government Board, and partly to the nature of their work, which does not give rise to so much personal feeling and prejudice. They are also subject to a much more careflfl and detailed inspection by the Government inspectors. This, no doubt, has its disadvantages, and has in some respects hampered t h e more far-seeing and enterprising boards; but from the point of view of efficiency the abolition of boards of guardians is not by any means so urgently demanded as the abolition of our rflral and smaller urban district councils. These bodies have been weighed in the balance, and found wanting. T h e y have, time and again, been pilloried by the Local Government Board for gross neglect and default; they have lately been subjected to the satiric shafts of the Chancellor of the Exchequer; yet they are still alive, and have even escaped the attentions of a Royal Commission. One would have thought that the numerous instances of default on the part of district councils that have been brought to light by the inspectors of the Local Government Board would have compelled our legislators to have devised long ago some effective remedy. But, apart from advice, ineffective threats, and the insertion of defaulting clauses in recent Acts, nothing of any consequence has been done. The latest attempt appears in the Insurance Act, where the inept, but truly British, method is sanctioned of giving power to still another authority to fine the sanitary authorities for excessive amounts of sickness in their areas. This is going one better than the clause in the Housing and Town Planning Act, where the servant of one authority is penalised for not giving information gratuitously to the servant of another authority. T o what a pass has local government arrived in this country ! There are many other disadvantages attaching to the present system. One is that the existing sanitary areas are far too small for modern administrative purposes, and they are not in anyway related to the areas of Poor Law unions or registration districts. Nor, as a rule, are their boundaries marked out with any scientific regard to watershed and drainage areas. Hence there is both statistical and engineering confusion. BI
128
PUBLIC
A striking illustration of unscientific boundarymaking came under my notice in connection w i t h the recent extension of a large city. At one place the new boundary line was drawn along one side, not in the middle, of a main road, so that the whole of that part of the road has to be maintained by the district council. The levels were such that the drainage of new houses built on the district side of the road had no outlet except into the city sewer; but, worse than that, the drainage of some of the houses built on the city side of the road could not possibly get into the city sewer. That results from tracing the boundary line on a map without sufficient study of the contour lines or inspection of the locality. There is also quite an unnecessary amount of overlapping in the work of local authorities. Instead of improving, it is getting worse. There are, for example, in many districts .whole-time school medical officers traversing in some instances the same areas as the local medical officers of health, both going into the same schools, sometimes for the same, more often for a different, purpose. There is supposed to be co-operation between them; but is not this co-operation more a figment of the official imagination than anything else ? The administration of sanatorium benefit will cause further overlapping, and tile Milk Bill will probably have the same effect. Then there are health visitors appointed by district councils, school nurses appointed by county councils, lady visitors appointed by boards of guardians to visit the homes of boarded-out children and the children of parents in receipt of relief, all going over the same ground, and lady tuberculosis visitors will no doubt shortly be treading on their heels. School attendance officers and relieving officers together obtain valuable information regarding the bulk of the industrial population" which would be most useful to sanitary authorities, and would be available if there were any sort of co-ordination of local work. Another disadvantage of the present system is the want of uniformity of sanitary administration in adjoining districts and the impossibility of attaining it. Is it right, for example, that cowkeepers in one district should be under a more or less rigid system of veterinary inspection while those in an adjoining district are free from inspection altogether ? Again, does anyone think it likely that town-planning will proceed apace in the W e s t Riding with its I59 sanitary districts ?
HEALTH.
FEm~UAI~V,
I need not say much regarding the anomalous position of the medical officer of health, who has, in effect, to criticise his own master, and report on his shortcomings to two or three higher authorities, and who has constantly to inspect, and report on defects on the property of members of the authority that employs him. Even if he had satisfactory tenure of office and were adequately paid, he could not h a y e a peaceful life while such a Gilbertian state of things existed. Is there any other official in the kingdom who is placed in such an extraordinary position ? Imagine the chaos that would result in the administration of the Factory Acts if the inspectors were employed and paid, in whole or in part, by the owners of the factories. The marvel to me is not that there is occasional friction between the official and his authority, but that it is not all friction. W e are trulya phlegmaticrace to have tolerated such a tragi-comic arrangement so long. Looking then to the past and still more to the future, I think that a radical change in the constitution of local health authorities and in the conditions of the public health service, at all events in county areas, is urgently demanded. It is not, perhaps, easy to find a simple scheme of reconstruction. So many local and personal interests are involved and such a fetish is now made of local government that it will be difficult to stay the hybrid monster. Some find a remedy in the creation of a Government Health Department with a responsible Mimster of Health at its head, Personally, I am not one of those enthusiasts who think progress is necessarily made by a mere change in nomenclature. So tong as local authorities remain as they are it will not make much difference whether the Right Hon. John Burns is designated President of the Local Government Board or Minister of Health. That seems to me to be beginning at the wrong end. It is the local, not the central, body that has to be strengthened and endowed with greater dignity. If, then, the local authorities are so weak and untrustworthy that no Government thinks of entrusting them with the administration of any new important departure in public health legislation, the powers that be should see to it that their multiplication is not sanctioned without the most cogent reasons being forthcoming. But, unfortunately, small urban districts are frequently being formed on some pretence of a hypothetical betterment in local government which rarely ensues. Dr. Newsholme,
1913.
PUBLIC ~EALTH.
speaking of inefficient units of administration, says *that " some of the most flagrant examples are to be found in the West Riding, in which inefficient urban districts have been formed under the powers given to the County Council by the Local Government Act, I888, which enabled them to carve urban districts out of rural districts within the administrative county, the Local Government Board having no power to prevent the formation of these inefficient districts unless the rural or urban distrfcts concerned opposed the proposed action and appealed to the Board. At the same time, very little action has been taken by this and other county councils to act on their powers to form more satisfactory units for local government when the present units were obviously inefficient and extravagant." The county c o u n c i l s have, therefore, in this respect failed to rise to the modern occasion, and have adopted the retrograde course of splitting up, instead of amalgamating, areas. The policy of amalgamation has a good deal to be said in its favour. It has been successful in the case of the Pottery Towns, and what does the extension of large cities mean but the amalgamation of the city with the surrounding urban or rural areas. The objection which is commonly raised to the' formation of large sanitary units, which include urban as well as rural localities, is the difficulty of equable rating; but this is largely of the nature of a bogey, for there appears to be ample power in the Public Health Acts of forming special districts within that area for the particular purpose required. The fact is also overlooked that many of our large towns now includewithin their boundaries considerable rural areas, and nothing is ever heard after a few years of anomalies of rating. Sanitary districts might be amalgamated straightway without losing any of their powers, or they might be combined for the purpose of carrying out all their duties that are of sanitary import, leaving their other functions intact, such as the maintenance of district roads, the pro~'ision of recreation grounds, public libraries, museums, baths, etc. The best scheme, perhaps, would be to remove all their sanitary duties from existing councils, and to throw them on the county council. It is, of course, indefdnsible that there should be two authorities in the s a m e area, each with sanitary powers limited in one or another direction. The evolution of local government has, moreover, tended to concentrate all really important matters in the county * PUBLIG }~rI~ALTH, A u g u s t ,
1909.
129
council. This development seems to be, on the whole, on right lines. I do not say that county councils are above criticism, I do not admire some of their methods an 3' more than I respect some of their motives. But the larger the body the less parochial it tends to be, and the tess chance is there of petty personal interests predominating to the detriment of the public weal. Such a system has worked well in Scotland. In England some of the counties have become so populous and the work thrown on the county councils has so increased of late years that few men can be found with the necessary leisure for committee work, and the real power in consequence rests in the hands of a few men. In this sense the county council is not a truly democratic body; but so far as health matters are concerned it is none the worse for that. This difficulty could be easily surmounted by dividing the county into wards or districts, each district being administered by a district committee, on whom the necessary powers would be conferred. The unification of all sanitary and related sanitary work could then easily be attained. Other methods of solving the problem seem to me to be either partial in their remedial value or impracticable. Some good would undoubtedly be accomplished in the way of stimulating local authorities if, after the manner of the Housing Regulations, definite regulations were drawn up by the Local Government Board, and enforced in regard to other branches of public health work. Government by regulation has its advantages. The Housing Regulations have given a greater impetus to the systematic inspection of, and the carrying out of structural improvements in, dwelling-houses than all the Housing Acts put together. An extension of this principle would be useful, though it would not promote the unification of areas and offices, which is so desirable. The giving of Government grants to local authorities as a bonus for efficient administration and as an aid in the provision of works of sewage, or water supply, or in the erection of working.class dwellings in small localities, where the expense of providing these is out of all proportion to the rateable value, would also be beneficial; but these could be granted equally to the larger as to the smaller units. The combination of districts for the purpose of appointing a whole-time medical officer of health is good so far as it goes ; but it does not go very far so long as the existing sanitary units remain.
180
PUBLIC HEALTH.
The ideal, so far as the medical officer of health is concerned, would be the establishment of a real State health service, the medical officers being appointed and paid by, and responsible only to, the State, as the factory inspectors are. This may sound somewhat Utopian, but I see no inherent difficulty in an arrangement of this sort. If no alteration were contemplated in the existing authorities it would be far better than any security of tenure of office. This has to some extent improved,but is not yet entirely satisfactory. Dr. Newsholme thinks that "efficient sanitary administration demands the extension of satisfactory conditions of tenure of office " - - a n d I should add, the superannuation of sanitary officers--" and the most satisfactory settlement of the problem will come in connection with the establisbment of efficient units of local government." The time is now, I think, ripe for a solution of this administrative problem. Preventive medicine has been placed on a high pedestal, and we cannot allow any part of the masonry to be defective or insecure. CITY OF NOTTINGHAM.--Dr. Boobbyer's report for I9II is specially noteworthy for the amount of detail given and analysis carried out in connection with the various causes of death. A considerable increase in the number of deaths from cancer is noted, and on the question of the relation of improved diagnosis to this Dr. Boobbyer points out that the deaths ascribed to cancer of the skin, respecting tbe diagnosis--of which there is not likely to have been at any time much difficulty or doubt--have remained singularly uniform in number year after year. Diarrhoea, enteric fever, and tuberculosis are all very fully considered. In connection with enteric considerable improvements are noted, which are ascribed to the fact that pail-closets are rapidly disappearing, and water-closets taking their place. In the appendix an exceedingly interesting special report on pail-closets is reprinted, and in the introductory letter it is noted that the council have arranged to assist owners to bear the cost of conversion of such closets into water-closets. Other special reports reproduced relate to tuberculosis, and deal with sanatorium benefi~ and the tuberculosis dispensary. The percentage of births notified under the Notification of Births Act was 68.2. Up to the present persons failing to notify have not been prosecuted. Dr. Boobbyer, however, considers that the time for bringing legal pressure to bear has arrived. The inspectorial staff, though apparch tly small, accoun ted for a considerable amo tint of work and great improvements, especially in the matter of housing, are looked for in the future.
FEBRUARY,
THE TREATMENT OF SCARLET FEVER BY S T R E P T O C O C C A L VACCINES. ~ By NORMAN H. WALKER, M.B., B.S., London, M.R.C.S., L.R.C.P., D.P.H., Late Assistant M.O.H., Willesden, and Deputy Medical Superintendent, Willesden Isolation Hospital. Fever problem is one that may T H Ebe Scarlet looked at from many points of view, and these vary according to the particular branch of the medical profession in which the observer is engaged. Of the many difficulties encountered, that of diagnosis is perhaps the most common. Anyone who has had to make a definite diagnosis in cases of doubtful scarlet fever on the first occasion of seeing them, whether he be general practitioner, medical officer of health, or superintendent of an isolation hospital, must at times have felt the want of some positive test for the disease. Similarly all will agree, I think, that we badly require some reliable means of judging when a case is no longer infectious. At the present time, ira case of the disease gives rise to a " r e t u r n " case either of the " h o s p i t a l " or " h o m e " denomination, the primary case is known to be still infectious or to have developed a recrudescence of infectiousness--a not uncommon occurrence, as Dr. Butler, of Willesden, has pointed out. This, as a test for infectiousness, is positive but extremdy unfortunate when verified. In the case of diphtheria the bacteriological examination enables one to make a certain diagnosis in doubtful cases, and aids One to decide when isolation is no longer necessary. W h e n the causal organism of scarlet fever is certainly discovered, similar help should be forthcoming in the case of the latter. The immense amount of research work that has already been undertaken on the bacteriology of this disease has, I think, left many unconvinced that the Streptococcus Scartatin~e of Dts. Klein and Gordon or the Streptococcus Conglomeratus of Kurth is really the causal organism. Since the Hendon outbreak in I885, when Dr. Klein isolated streptococci from the blood during life in four out of eight cases examined by him, which organisms he identified with those obtained from lesions on the udders of the cows, numerous attempts have been made to bring in a verdict of guilty against one *A paper read at a meeting of the H o m e
Counties Branch of the
So~;iety of ModiGal Officers of Health.