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The public vaccinator v. the private practitioner
PUBLIG HEALTH: 3ournaI of the 3ncorporat¢ fll3¢ ical Omccr VoL. XIV.
ociet ? of
of 1health.
No. 6.
MAlice, 1909..
EDITORIAL. THE PUBLIC VACCINATOR V. THE PRIVATE PRACTITIONER. THE prevalence of small-pox in London and in other sanitary districts which have been infected from it has led to the manifestation of a considerable amount of activity in preventive measures among the sanitary authorities, and to a less extent among the Boards of Guardians of invaded or threatened districts. Among the evidences of activity has been the distribution, house to house or by street posters, of advice as to revaccination ; and at this point some confusion is apt to, and has," in fact, here and there occurred, owing to the fact that t h e official machinery for public vaccination is in the hands of the Boards of Guardians. If a Board of Guardians issue, as has been done in certain districts, circulars recommending revaecination, and in this circular give particulars as £o the official facilities for vaccination offered by their public vaccinators, we suppose that no objection is likely to be taken by medical practltioners to this course. So long as the Board of Guardians are the authority responsible for the execution of the vaccination laws, and so long as special public vaccinators exist in every district, the additional publicity to official vaccination given by these circulars and posters is obviously in the public interest. In some districts, however, the local Board of Guardians are lethargic, or even obstructive. They do not desire to see theh" charges for revaccination increased, and even in the face of a threatened epidemic are content to let revaecination slide. Under such circumstances it is not surprising that many local sanitary authorities have issued posters and circulars advising revaccination, signed by their clerk or medical officer of health. If the latter receives instructions to issue such a circular, we can imagine him to 22
326
P u b h c V a c c i n a t o r v. P r i v a t e P r a c t i t i o n e r
~r~blt¢~e~ltl~
be placed in a somewhat delicate position in relation to the general medical practitioners practising within his district. Either, in addition to describing the local facilities for gratuitous revaccination in the district, he will refer those who are not poor to their family doctor, who will revaccinate for a fee, or he will not. If he takes the latter course, he is simply doing what the Board of Guardians, the authority responsible for vaccination, would have done had they issued a circular. If he takes the former course, he is in danger of falling into one or more pitfalls, which in the interest of the public health it is desirable that he should avoid. He may, if he snggests class distinctions in regard to vaccination, bring vaccination by Poor Law officers into disrepute, and may thus greatly hinder resort on the part of the somewhat poor (though not paupers)to the public vaccinator. He is in danger, furthermore, of turning the balance against being revaccinated at all on the part of those who, though able to pay a reasonable fee for revaccination, will not do so when gratuitous revaccination is provided ; and will not, under the given circumstances, go to or send for the public vaccinator because of possible reflections upon them from a social standpoint. There are many in every district who, with some show of reason, have come to look upon the provision of gratuitous vaccination and revaccination as being a sanitary measure which ought to be chargeable to the local authority, in the same way as is the gratuitous pro~dsion of isolation hospital accommodation, which is now made in nearly all sanitary districts, irrespective of social conditions. A further point has recently come to our notice. Medical officers of health are being applied t o by well-to-do residents in their districts as to whether they can arrange for revaccination by the "Government lymph." This form of application, although not at present in the interest of the private practitioner, shows that with officially-guaranteed lymph there is likely to be a diminishing difficulty in securing vaccination. We have set down the preceding considerations in order that the difficulty they illustrate may be looked at both from the standpoint of the medical practitioner and of the medical officer of health. We think that the latter is practically bound to confine himself, as matters now stand, to a description of the local official machinery for vaccination. We think that the former have a grievance which can only be met by two urgent reforms of vaccination administration. :Firstly, every medical practitioner should be supplied with vaccine lymph from the Government calf-lymph stations, or with lymph under Government guarantee ; and, secondly, every medical
m~ch,190~.~
Position oI M.O.H. in Scotland
327
practitioner should be a public vaccinator in his own district, so that the entire medical profession would be interested in securing efficient multiple vaccination, and not that apology for vaccination which now, unfortunately, passes muster among a certain class of practitioners. THE POSITION OF MEDICAL OFFICERS OF H E A L T H AND SANITARY INSPECTORS IN SCOTLAND. IT iS with regret, but not with surprise, that we observe in the daily press that there is serious friction in the Health Department in Glasgow between the two chief officers. When the Public Health (Scotland) Act was passed, the medical officer of health and the sanitary inspector were made co-ordinate officers, independent of one another. No very clear reason was ever given for this course, but it was hinted that it was a device to prevent too much work being done. If that was the object, ~hose who promoted that policy must have foreseen that friction would possibly arise between the two officers, and the energy which should have been concentrated on improving the state of the public health would be wasted in conflict. Fortunately, in many instances, the friction has been reduced to a minimum, but this has only been achieved in some cases by sacrificing work which could only be done by the mutual co-operation of the two officers. The Local Government Board for Scotland has evidently recognised the difficulty which might occur, and has issued alternative sets of model regulations, either of which may be adopted by local authorities. One of these is based on the supposition that the public health work shall be conducted as one department; the other, that there shall be two independent sub-departments. Before the passing of the Act of 1897 Glasgow worked on the lines of having a Health and a Sanitary Department independent of one another, and so long ago as 1885 Dr. J. B. Russell pointed out that with the development of public health work the system would lead to confusion, inefficient and costly administration, and to such a state of affairs as might prove a serious menace to the general health. To remedy this condition in a large city like Glasgow there are two courses open--either to make one department, or to provide the medical officer with an efficient staff whereby he can carry out his statutory duties. The objection, however, to this is that there is apt to be a double inspection of premises, with the always present possibility that there may still be some disagreement between the staff of the two sub-departments: From the discussion at a recent meeting of the Glasgow Town 22--2
ociet ? of
of 1health.
No. 6.
MAlice, 1909..
EDITORIAL. THE PUBLIC VACCINATOR V. THE PRIVATE PRACTITIONER. THE prevalence of small-pox in London and in other sanitary districts which have been infected from it has led to the manifestation of a considerable amount of activity in preventive measures among the sanitary authorities, and to a less extent among the Boards of Guardians of invaded or threatened districts. Among the evidences of activity has been the distribution, house to house or by street posters, of advice as to revaccination ; and at this point some confusion is apt to, and has," in fact, here and there occurred, owing to the fact that t h e official machinery for public vaccination is in the hands of the Boards of Guardians. If a Board of Guardians issue, as has been done in certain districts, circulars recommending revaecination, and in this circular give particulars as £o the official facilities for vaccination offered by their public vaccinators, we suppose that no objection is likely to be taken by medical practltioners to this course. So long as the Board of Guardians are the authority responsible for the execution of the vaccination laws, and so long as special public vaccinators exist in every district, the additional publicity to official vaccination given by these circulars and posters is obviously in the public interest. In some districts, however, the local Board of Guardians are lethargic, or even obstructive. They do not desire to see theh" charges for revaccination increased, and even in the face of a threatened epidemic are content to let revaecination slide. Under such circumstances it is not surprising that many local sanitary authorities have issued posters and circulars advising revaccination, signed by their clerk or medical officer of health. If the latter receives instructions to issue such a circular, we can imagine him to 22
326
P u b h c V a c c i n a t o r v. P r i v a t e P r a c t i t i o n e r
~r~blt¢~e~ltl~
be placed in a somewhat delicate position in relation to the general medical practitioners practising within his district. Either, in addition to describing the local facilities for gratuitous revaccination in the district, he will refer those who are not poor to their family doctor, who will revaccinate for a fee, or he will not. If he takes the latter course, he is simply doing what the Board of Guardians, the authority responsible for vaccination, would have done had they issued a circular. If he takes the former course, he is in danger of falling into one or more pitfalls, which in the interest of the public health it is desirable that he should avoid. He may, if he snggests class distinctions in regard to vaccination, bring vaccination by Poor Law officers into disrepute, and may thus greatly hinder resort on the part of the somewhat poor (though not paupers)to the public vaccinator. He is in danger, furthermore, of turning the balance against being revaccinated at all on the part of those who, though able to pay a reasonable fee for revaccination, will not do so when gratuitous revaccination is provided ; and will not, under the given circumstances, go to or send for the public vaccinator because of possible reflections upon them from a social standpoint. There are many in every district who, with some show of reason, have come to look upon the provision of gratuitous vaccination and revaccination as being a sanitary measure which ought to be chargeable to the local authority, in the same way as is the gratuitous pro~dsion of isolation hospital accommodation, which is now made in nearly all sanitary districts, irrespective of social conditions. A further point has recently come to our notice. Medical officers of health are being applied t o by well-to-do residents in their districts as to whether they can arrange for revaccination by the "Government lymph." This form of application, although not at present in the interest of the private practitioner, shows that with officially-guaranteed lymph there is likely to be a diminishing difficulty in securing vaccination. We have set down the preceding considerations in order that the difficulty they illustrate may be looked at both from the standpoint of the medical practitioner and of the medical officer of health. We think that the latter is practically bound to confine himself, as matters now stand, to a description of the local official machinery for vaccination. We think that the former have a grievance which can only be met by two urgent reforms of vaccination administration. :Firstly, every medical practitioner should be supplied with vaccine lymph from the Government calf-lymph stations, or with lymph under Government guarantee ; and, secondly, every medical
m~ch,190~.~
Position oI M.O.H. in Scotland
327
practitioner should be a public vaccinator in his own district, so that the entire medical profession would be interested in securing efficient multiple vaccination, and not that apology for vaccination which now, unfortunately, passes muster among a certain class of practitioners. THE POSITION OF MEDICAL OFFICERS OF H E A L T H AND SANITARY INSPECTORS IN SCOTLAND. IT iS with regret, but not with surprise, that we observe in the daily press that there is serious friction in the Health Department in Glasgow between the two chief officers. When the Public Health (Scotland) Act was passed, the medical officer of health and the sanitary inspector were made co-ordinate officers, independent of one another. No very clear reason was ever given for this course, but it was hinted that it was a device to prevent too much work being done. If that was the object, ~hose who promoted that policy must have foreseen that friction would possibly arise between the two officers, and the energy which should have been concentrated on improving the state of the public health would be wasted in conflict. Fortunately, in many instances, the friction has been reduced to a minimum, but this has only been achieved in some cases by sacrificing work which could only be done by the mutual co-operation of the two officers. The Local Government Board for Scotland has evidently recognised the difficulty which might occur, and has issued alternative sets of model regulations, either of which may be adopted by local authorities. One of these is based on the supposition that the public health work shall be conducted as one department; the other, that there shall be two independent sub-departments. Before the passing of the Act of 1897 Glasgow worked on the lines of having a Health and a Sanitary Department independent of one another, and so long ago as 1885 Dr. J. B. Russell pointed out that with the development of public health work the system would lead to confusion, inefficient and costly administration, and to such a state of affairs as might prove a serious menace to the general health. To remedy this condition in a large city like Glasgow there are two courses open--either to make one department, or to provide the medical officer with an efficient staff whereby he can carry out his statutory duties. The objection, however, to this is that there is apt to be a double inspection of premises, with the always present possibility that there may still be some disagreement between the staff of the two sub-departments: From the discussion at a recent meeting of the Glasgow Town 22--2