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The public health aspects of evacuation
PUBLIC H E A L T H other hand, new applications for commissions sent direct to any of the Services will not be accepted without prior reference to the Central Emergency Committee, which is guided as to its approval by the local committee of the area where the practitioner resides. So far the Services have not asked for men over 50 years of age, although a few older men who are outstanding figures in medicine have been engaged for exceptional posts. The Central Emergency Committee has informed local committees that, in its opinion, no man under 35 years of age should be earmarked for work in connection with civil defence or the Civilian Hospital Emergency Medical Service. The latter Service, it may be noted, is not recruited from those in the regular employment of the Government or local authorities. For civil defenee the general policy has been to approve only of men well above the minimum age of 35, although in most areas it has been impossible to confine the staffing of first-aid posts to men over 50, even by making the fullest use of the medical women locally available. Briefly, then, the position is this. Emergency committees have so far exercised no compulsory powers. Any placement or transfer must be made with the consent of the practitioner involved. It appears to follow that no whole-time officer can be moved without the consent of his local authority, unless he is prepared to resign his appointment with all the consequences which this may entail. There are signs that certain local emergency committees do not clearly understand their own limitations, or realise that no action should have been initiated by them for the recruitment of public health officials for any other service without first of all consulting the local authority, or, at least, the medical officer of health. On the other hand, local authorities in some areas do not appear to appreciate the magnitude of the coming demand for medical personnel. It would be unreasonable to expect local emergency committees to endeavour to meet all the requirements of the Services from the ranks of those who have acquired private practices, which may evaporate before they return, and not to seek a fair contribution from the ranks of those whose posts will be, or ought to be, secured for them. A matter which may present some difficulty is the movement of members of public health staffs in evacuation areas to supplement the corresponding departments in receiving areas or other departments which have been unavoidably depleted. It is understood that a certain number of assistants in evacuation areas may become surplus to establishment in spite of the heavy burden of air-raid precautions. Where large numbers of mothers and children have left a
OCTOBER district, some of the women medical officers, in particular, might become available for work elsewhere. If arrangements are contemplated for inviting them to transfer, it ought to be ensured that their present salary, prospective increments and pension rights are maintained, and that they shall return to the posts they now hold as soon as activities are resumed, and, in any case, on the restoration of peace conditions. No concrete plan seems to exist at the time of writing. In the meantime a list of public health officers, mostly retired, who are available for work is being compiled by the Central Emergency Committee with the Society's collaboration, and men and women in this category are invited to communicate with the Secretary and Editor. Two other points of interest to the public health service may be mentioned. Medical practitioners accepted as specialists in the R.A.M.C. within the authorised establishment, will receive almost immediately the rank and emoluments of Major. A similar improvement of status will take effect in the R.A.F., while the position of specialists in the Royal Navy is still under consideration. Presumably this advance applies to medical officers accepted as specialists in hygiene, bacteriology and several other branches of medical science in which members of the health service are engaged. Secondly, the status of women practitioners engaged by the War Office has now been satisfactorily settled. Their emoluments and conditions of service will be substantially the same as for men.
The Public Health Aspects of Evacuation The Government evacuation scheme has already caused attention to be drawn to the unclean co~adition of some children from the cities and to the prevalence of such conditions as scabies. The transfer of thousands of children to the less thickly settled areas of the country will certainly involve outbreaks of infectious disease, of which the incidence may fall more heavily on the country children whose level of immunity against the common infections is lower than that of the new arrivals. It is unnecessary to say that thorough control of the epidemic situation and proper care of the health of the child population will be most important factors in reconciling the public to the sudden and vast dislocation of peace-time life involved by an evacuation which will probably have to remain in operation for a period not of months but of years. The staffs of public health departments-doctors, nurses, sanitary inspectors and clerical-therefore have a great responsibility. What is the present position? In the larger centres of popu-
1939 lation staffs are, and have been for months, heavily engaged on duties connected with civil defence, rather than with public health. In the reception areas staffs which have only just been adequate for peace-time work now have to deal with the public health provision for an enormously increased population. So far no clear directions have been given by the Ministry of Health about the obviously needed transfer of public health personnel, although Circular 1,871 of September 12th refers to the resumption of school medical inspection, to the existence of verminous conditions or skin troubles among evacuees and to a forthcoming circular on medical matters. The only definite medical step has been the agreement with the B.M.A. for the payment of a capitation fee to private practitioners who treat cases of illness amongst the evacuated children. Meanwhile, many assistant medical officers in the evacuation areas are being retained for duties in hospitals and aid posts for which they have little aptitude or inclination and would be readily seconded to the reception areas which now house their child populations. Some individual medical officers of health on their own initiative are already arranging the transfer of some of their medical and nursing staffs to reception areas, but we think that, in a matter of such national scope and importance, a clear lead is wanted from the central department with details of conditions of service for the transferred officers. We welcome the important step which has been taken in at least one direction. It will be seen from Sir Arthur MacNalty's letter and memorandum, which we reproduce on page 14, that an Emergency Public Health Laboratory Service has been established throughout the country by the Medical Research Council in co-operation with the Ministry of Health. We understand that the whole scheme was carefully worked out some months ago and was put into operation within a day or two of the outbreak of war. It will be noted that the service does not supplant, but is meant to supplement, the facilities which already exist in a number of areas; nor does the service undertake pathological work of the kind ordinarily done in the laboratories of a general hospital. It is intended that the function of these additional laboratories should be essentially epidemiological in character. Their object is to aid in the diagnosis and control of infectious disease and to act as centres for the distribution of prophylactic reagents. No charge will be made for the services they render. Many medical officers of health will have for the first time a well staffed and equipped laboratory within a few miles of their offices. If, however, these laboratories are to yield their full measure of usefulness medical officers of health
PUBLIC HEALTH must get in touch with the officers in charge and must seek their assistance in all cases of doubt. A medical officer of health who, in the past, has had to send every laboratory specimen to a town many miles distant from his district and has had to pay a fee for every examination made may feel some diffidence in making full use of this new service. Such diffidence is quite unnecessary, for not only will he get the laboratory help he needs but he will find that the officer in charge of the laboratory will even be prepared, if circumstances permit, to visit an infected area and assist in the collection of material and in any other ways open to him. To achieve its full effectiveness the laboratory service should have associated with it an emergency group of epidemiologists. It is just as important that the civil population should feel that all measures are being taken to safeguard the health of the children of this country as that our fighting services should have their full complement of medical officers. It is hoped that the Ministry of Health will take steps, possibly by the attachment of additional medical officers to the staffs of their new regional medical officers, to ensure that everything possible is done to prevent the spread of infectious disease. The problem is no longer a local one ; the evacuation scheme has made it one of first-class national importance.
The Ministry of Health Report, 1938-39 The 20th Annual Report* of the Ministry of Health for the year ended March 31st, 1939, contains one new Part, relating to Civil Defence under the heads of Medical Services and Evacuation, subjects which Mr. Elliot, in his foreword says" are likely to take their place for the immediate future as permanent additions to the list of public social services." These matters have certainly had priority over public health work and preventive medicine, especially during the past year, and, unfortunately, we have now had to see the preparatory work of the Ministry and local authorities .put into operation. The immensity of the task is shown by the fact that arrangements were made to have available 290,000 beds for war casualties (100,000 by sending home ordinary sick, 100,000 by introducing extra beds into existing hospitals, 50,000 by introducing further beds if necessary, and 40,000 by means of huts). Such questions as whether the public interest is best being served by the appropriation of sanatoria for war casualties, with the result that cases of open tuberculosis have been sent back to homes where the normal occupancy may have been increased by the billeting of evacuees, remain to be solved in the *Cmd. 6089. H.M. Stationery Office.
Price 5s. net. 3
OCTOBER district, some of the women medical officers, in particular, might become available for work elsewhere. If arrangements are contemplated for inviting them to transfer, it ought to be ensured that their present salary, prospective increments and pension rights are maintained, and that they shall return to the posts they now hold as soon as activities are resumed, and, in any case, on the restoration of peace conditions. No concrete plan seems to exist at the time of writing. In the meantime a list of public health officers, mostly retired, who are available for work is being compiled by the Central Emergency Committee with the Society's collaboration, and men and women in this category are invited to communicate with the Secretary and Editor. Two other points of interest to the public health service may be mentioned. Medical practitioners accepted as specialists in the R.A.M.C. within the authorised establishment, will receive almost immediately the rank and emoluments of Major. A similar improvement of status will take effect in the R.A.F., while the position of specialists in the Royal Navy is still under consideration. Presumably this advance applies to medical officers accepted as specialists in hygiene, bacteriology and several other branches of medical science in which members of the health service are engaged. Secondly, the status of women practitioners engaged by the War Office has now been satisfactorily settled. Their emoluments and conditions of service will be substantially the same as for men.
The Public Health Aspects of Evacuation The Government evacuation scheme has already caused attention to be drawn to the unclean co~adition of some children from the cities and to the prevalence of such conditions as scabies. The transfer of thousands of children to the less thickly settled areas of the country will certainly involve outbreaks of infectious disease, of which the incidence may fall more heavily on the country children whose level of immunity against the common infections is lower than that of the new arrivals. It is unnecessary to say that thorough control of the epidemic situation and proper care of the health of the child population will be most important factors in reconciling the public to the sudden and vast dislocation of peace-time life involved by an evacuation which will probably have to remain in operation for a period not of months but of years. The staffs of public health departments-doctors, nurses, sanitary inspectors and clerical-therefore have a great responsibility. What is the present position? In the larger centres of popu-
1939 lation staffs are, and have been for months, heavily engaged on duties connected with civil defence, rather than with public health. In the reception areas staffs which have only just been adequate for peace-time work now have to deal with the public health provision for an enormously increased population. So far no clear directions have been given by the Ministry of Health about the obviously needed transfer of public health personnel, although Circular 1,871 of September 12th refers to the resumption of school medical inspection, to the existence of verminous conditions or skin troubles among evacuees and to a forthcoming circular on medical matters. The only definite medical step has been the agreement with the B.M.A. for the payment of a capitation fee to private practitioners who treat cases of illness amongst the evacuated children. Meanwhile, many assistant medical officers in the evacuation areas are being retained for duties in hospitals and aid posts for which they have little aptitude or inclination and would be readily seconded to the reception areas which now house their child populations. Some individual medical officers of health on their own initiative are already arranging the transfer of some of their medical and nursing staffs to reception areas, but we think that, in a matter of such national scope and importance, a clear lead is wanted from the central department with details of conditions of service for the transferred officers. We welcome the important step which has been taken in at least one direction. It will be seen from Sir Arthur MacNalty's letter and memorandum, which we reproduce on page 14, that an Emergency Public Health Laboratory Service has been established throughout the country by the Medical Research Council in co-operation with the Ministry of Health. We understand that the whole scheme was carefully worked out some months ago and was put into operation within a day or two of the outbreak of war. It will be noted that the service does not supplant, but is meant to supplement, the facilities which already exist in a number of areas; nor does the service undertake pathological work of the kind ordinarily done in the laboratories of a general hospital. It is intended that the function of these additional laboratories should be essentially epidemiological in character. Their object is to aid in the diagnosis and control of infectious disease and to act as centres for the distribution of prophylactic reagents. No charge will be made for the services they render. Many medical officers of health will have for the first time a well staffed and equipped laboratory within a few miles of their offices. If, however, these laboratories are to yield their full measure of usefulness medical officers of health
PUBLIC HEALTH must get in touch with the officers in charge and must seek their assistance in all cases of doubt. A medical officer of health who, in the past, has had to send every laboratory specimen to a town many miles distant from his district and has had to pay a fee for every examination made may feel some diffidence in making full use of this new service. Such diffidence is quite unnecessary, for not only will he get the laboratory help he needs but he will find that the officer in charge of the laboratory will even be prepared, if circumstances permit, to visit an infected area and assist in the collection of material and in any other ways open to him. To achieve its full effectiveness the laboratory service should have associated with it an emergency group of epidemiologists. It is just as important that the civil population should feel that all measures are being taken to safeguard the health of the children of this country as that our fighting services should have their full complement of medical officers. It is hoped that the Ministry of Health will take steps, possibly by the attachment of additional medical officers to the staffs of their new regional medical officers, to ensure that everything possible is done to prevent the spread of infectious disease. The problem is no longer a local one ; the evacuation scheme has made it one of first-class national importance.
The Ministry of Health Report, 1938-39 The 20th Annual Report* of the Ministry of Health for the year ended March 31st, 1939, contains one new Part, relating to Civil Defence under the heads of Medical Services and Evacuation, subjects which Mr. Elliot, in his foreword says" are likely to take their place for the immediate future as permanent additions to the list of public social services." These matters have certainly had priority over public health work and preventive medicine, especially during the past year, and, unfortunately, we have now had to see the preparatory work of the Ministry and local authorities .put into operation. The immensity of the task is shown by the fact that arrangements were made to have available 290,000 beds for war casualties (100,000 by sending home ordinary sick, 100,000 by introducing extra beds into existing hospitals, 50,000 by introducing further beds if necessary, and 40,000 by means of huts). Such questions as whether the public interest is best being served by the appropriation of sanatoria for war casualties, with the result that cases of open tuberculosis have been sent back to homes where the normal occupancy may have been increased by the billeting of evacuees, remain to be solved in the *Cmd. 6089. H.M. Stationery Office.
Price 5s. net. 3