- Email: [email protected]
THE SCHOOL HEALTH SERVICE AND THE FAMILY DOCTOR
101
respiratory movements were possible and in no way hindered by the median sternotomy. Soon after operation I developed a nodal tachycardia with associated dyspnosa. Sinus rhythm was regained, however, during a four-week course of digoxin. Subjectively, dyspnoea and tachycardia are both very distressing symptoms, which merit careful investigation and treatment by the physician. By the fourth postoperative day I was able to sit up for a short while, and I was able to walk (with assistance at first) from the sixth day. full
Until the sixth week I had occasional bouts of
extra-
systoles, accompanied by transient feelings of faintness. The extrasystoles remitted without treatment, and for the past three months I have remained symptom-free. I should like
thank Prof. A. C. Dornhorst and Dr. Aubrey whose care I was and who have stimulated me to write this account. It is also a pleasure to record my debt to Dr. J. W. Kirklin and his team at the Mayo Clinic, Rochester, Minnesota, who kindlv undertook the ooerative closure of the lesion. St. George’s Hospital, to
Leatham, under
E. LETLEY
London, S.W.1
Public Health THE SCHOOL HEALTH SERVICE AND THE FAMILY DOCTOR BRIAN DIDSBURY M.B. Manc.,
D.P.H.,
D.P.A.
DEPUTY MEDICAL OFFICER OF HEALTH AND DEPUTY PRINCIPAL SCHOOL MEDICAL
OFFICER, WEST HAM
IT is natural for school doctors to take pride in the contribution their service has made to the health of children. But in each age and society methods of health promotion must be adjusted to changed circumstances and challenges. Our school medical service was designed at the beginning of this century to cope with conditions that no longer exist. It has largely continued on traditional lines, failing to take into account the improvement in child health in post-war Britain. Today 99 children out of every 100 examined at school are physically fit and every child has its own family doctor. Perhaps, therefore, many of the doctors and nurses working in the service (equivalent to more than 950 whole-time doctors and 2600 whole-time nurses) could now be employed more usefully elsewhere. In this paper I seek to redefine the role of the medical officer in the schools of today. THE WRONG
CHILD ?
Routine medical inspection of all schoolchildren was undoubtedly valuable in the early days of the service when many defects and diseases were detected and then treated. But nowadays the periodic inspections reveal comparatively few defects or diseases requiring treatment. The following are the figures for England and Wales in 1960-611 :
1. Based
on
the report of the Chief Medical Officer of the p. 233.
Education, 1960-61, table VIII,
Ministry of
School medical officers are required to record these defects or diseases " as requiring treatment " irrespective of whether the child is, or is not, under treatment at the time of examination. Moreover, the record fails to differentiate between the serious and the minor variations. Yet it is surely important to know the true incidence of serious defects and diseases and whether they are being treated. There are no national statistics for this, but the Chief Medical Officer’s report now has a small section on " defects not being treated ", based on inquiries conducted by three authorities. Apart from defects of vision and hearing, there is considerable truth in the criticism that the service is finding defects that have already been noted by family and hospital doctors and which are being treated. In 1961 2 million schoolchildren were examined at periodic medical inspections and over 720,000 at special inspections. Was this a useful expenditure of medical and nursing time ? Was it justified in terms of the disruption of classes and school routine ? The answer must be a qualified No. Because of the improvement in child health and the diagnostic and treatment facilities observed by the National Health Service, the school service should concentrate on selected children rather than dissipate its attention on the wholesale medical examination of all pupils. The need for a changed approach has long been appreciated by the Ministry of Education, but the response of the local authorities has been disappointing. The cautious experiments of the bolder authorities have more than justified the new methods. These vary from authority to authority, but the basic pattern consists of a health conference followed by the examination of selected
pupils. The nucleus of the conference is the head teacher, the nurse, supplemented if necessary by other persons, such as the class teacher or the school welfare officer. At the conference, the head teacher will bring forward the names of the pupils who have caused concern to the teaching staff by ill health, absence from school, or behaviour in class. The school nurse will suggest which children should have a medical examination based on her observations during vision testing, hygiene surveys, and contacts with their families, whom she meets in her other capacity as the district health visitor. The doctor will usually have looked at the children’s school and maternal and child-welfare health record cards. He may make a quick tour of the school to watch children at work and at play.
doctor, and the school
The virtue of such
scheme is that all the children are an enlarged health team which welcomes the teacher’s observations. More than the normal 6-7 minutes is allowed for the medical examination and consultation with the parent. The method has been used to replace the middle-school examination at 10 or 11 years, and as an alternative for school-leavers. There is no real reason why it should not be used in infant schools. The maternal and child-welfare records should be helpful with this age-group and the health-visitor/school-nurse should know " her children ’’ and " her homes ". But it is not a substitute for screening tests of vision and hearing. Unfortunately few authorities have sought the views of the general practitioners about the children selected for examination. This is a pity because in general practice it is practically impossible not to know a family with young children, if they have been on " the list " for any length of time. With the new method the number of referrals is at first rather high, but with experience it tends to settle down to a more reasonable a
regularly considered by
102
Some authorities have made their task difficult by trying to select all pupils with any form of health problem instead of concentrating on those who have a problem which might affect their education. Once this division of labour is accepted, the new approach could be applied to all schools and save both educational and medical time.
rate.
THE WRONG
DOCTOR?
There has been a growing tendency to integrate the work of the school medical officer and the doctors of the maternal -and child-welfare services. This has been welcomed by the younger assistant medical officers because it has brought interest and variety to their work. The claim has also been made that it ensures continuous health supervision from infancy to adolescence. The important question which is usually avoided is whether the wrong doctor is doing the supervision-i.e., should not this be the role of the family practitioner rather than of the local-authority medical officers ? If we stop thinking of children as individuals and consider them as members of a family group, it will be obvious that the general practitioner is in a unique position to promote health. The family doctor who is interested in the early detection of disease in children, in the simple dynamics of health and sickness in the home, and in trying to ensure the health of the individual child is a first-rate practitioner of preventive medicine. Such doctors are not " rare birds ". The younger doctors in the public-health service and in general practice are not interested in the old antagonisms and feuds of the pre-1948 era. The climate is now favourable for a changed relationship as far as the school health service is concerned.
This does not mean that the general practitioner should carry out medical inspections in the school, nor sit in a school clinic or in his own surgery examining schoolchildren. But as a good family doctor he will extend his interest in his patients beyond episodes of illness. Parents should be told that if they are worried about their child’s health they should consult their family doctor in the first place. If the problem is likely to affect the child’s education, he will consult the school doctor, who should specialise in educational problems and not act as a convenient second opinion for the parent who does not trust her own doctor. The family doctor cannot observe the child in the school setting, and it would be unreasonable to ask him to test children’s vision or to make audiometric surveys. These investigations can be done by others and significant results brought to his attention by the school doctor. WRONG
TECHNIQUES
The periodic medical inspection is not a particularly efficient technique. Leeconcluded that only 60% of the defects which caused the rejection of young men for military service were noted on the record cards of the school health service. The Chief Medical Officer’s report reveals that in 1956 for every thousand children examined school entrants " 2 had squints in Halifax and 107 in as Stockport; 0-5 had discharging ears in West Ham and 109 in Salford; 1-4 had, or were suspected of having, heart-disease in Warrington and 50 in Burton-on-Trent and in Northampton; 0-8 had a hernia in Doncaster and "
2.
Lee, J. A. H. Brit. med. J. 1958, i, 573.
28 in Smethwick; 3 had " lung disease " in Cheshire and 124 in Dudley. In these circumstances, it might be better to examine thoroughly a representative sample of schoolchildren to provide national norms. Moreover, it is far less important to know the exact incidence of otitis media in schoolchildren than to be sure_that their parents will seek medical advice promptly. Otitis media can develop very quickly: at child may not been seen by the school doctor for several years under the present system of
periodic medical inspections. The chief safeguard of a child’s health is the education of his parents. Can we honestly say that a vigorous and effective attempt has been made to educate the public about the early signs and symptoms of diseases which affect schoolchildren or to encourage them to think of their family doctor not only as the person they consult when a child is ill but also about all health problems? Many authorities who have introduced the new method of health surveillance send a health questionnaire to all the parents and invite them to see the school doctor if they are worried about their child’s health. In these ways the authority fails to build up the image of the family doctor as a health expert. Minor-ailment clinics and artificial-light clinics are also anachronisms. The regular patrons of minor-ailment clinics come from nearby schools, yet the health of the children in the most distant schools seems unaffected, nor do the head teachers complain that pupils have difficulty in obtaining medical care. Another useless task of the school doctor is the medical examination of children who want to be errand boys or deliver newspapers. 2770 children were examined in Manchester in 1958 for " fitness for employment " and only 2 were considered unfit. Selection could obviously be introduced here with
profit. These anachronisms leave the school doctor neither time nor opportunity to make an effective contribution to health education, or to come to grips with the real problems of the modern child. Can anybody be happy about the tragedies that follow promiscuous sexual activities among teenagers ? What is the life expectation of the overweight school child ? Is the prognosis for the heavy teenage smoker more encouraging ? Other questions spring to mind which demand research and an organised multidisciplinary approach. 66 local educational authorities in England and Wales have child populations of less than 20,000 each. If school medical officers are shorn of their responsibility for the normal child and if the trend to specialisation continues-e.g., the medical and educational problems of the deaf child-some officers could be shared on a regional basis to carry out special investigations without regard to local-authority boundaries. TEACHER’S
VIEWPOINT
The teacher’s attitude towards the school health service is ambivalent. He appreciates that protracted illness or poor health is likely to hinder a child’s educational progress, but he would like it to be recognised in practice as well as in theory that the prime function of a school is education. At times the teacher feels that his school has become a too convenient appendage of the health department. In a short period a school can receive visits from a doctor for medical inspections and then for immunisa-
tions ; from a nurse for hygiene surveys and then for vision-testing; from an audiometrician; and, if it is very fortunate, from a dentist. Class work is interrupted,
103
programme and routine have to be adjusted, and the results are not always tangible. Matters are not improved if the members of the health team-and this unfortunately usually means the doctor-are not punctual or fail to establish a good relation with the headteacher. A real advantage of the newer methods that are replacing the periodic medical inspection is that they make the teacher a vital member of the school health team, and teachers welcome this new form of constructive
partnership. THE CHILDREN .
The service deals with three types of children: handicapped pupils, children with defects, and normal children.
Handicapped Children Out of a school population of 7 million,some 70,000 attend day or residential special schools for handicapped " pupils. Most of these children are described as educationally subnormal ". (They include dull and backward children, but not those whose intelligence quotient is under 50 who are usually trained outside the educational system.) The doctor’s main contribution to the training of these children is diagnosis of their handicap; some will need the help of a consultant. Close cooperation and teamwork between educationalists and doctors with special knowledge is needed if the handicapped pupil’s remaining talents and skills are to be developed to the full. This type of knowledge can be acquired by a family doctor. His other work may not allow him to find time for the necessary training, but when he can his relative permanency provides useful continuity. Children with
Defects
The needs of the child with a defect are rather different. Where the handicapped child’s chief medical needs are continuity in care and supervision, his are early diagnosis and prompt remedial action. Screening tests are essential for early detection of visual and hearing defects. Further experience is needed to evaluate mental-health screening tests. If they are to be generally adopted, it will be necessary to use the teacher’s ability to observe and assess the children in class, and she will need help and counsel from either the school doctor or nurse. At this stage it would be wrong to base our mental-health programme for schoolchildren on a search for mental pathology in every facet of behaviour. Child-guidance clinics are already overburdened and it would be sensible to make more use of the family doctor’s talents. It is, of course, easier to persuade a mother to give her child oral penicillin than to adopt a less rigid attitude towards the child who fails to conform to her concept of normality or acceptable behaviour. But the family doctor, because of his knowledge of the home, is in a better position to do this than the school medical officer. Only when the school situation is important need the local-authority medical officer be drawn in. Direct contact between the general practitioner and the class teacher is theoretically possible but is unlikely to be close. The link between him and the teacher should be the school doctor or possibly, and this may be better, the health visitor or school nurse, particularly if the health visitor is linked with the practice rather than based on a clinic. Normal Children
The link between the school and the family doctor should be strengthened also for normal children. If
parents knew that their health visitor was working in close cooperation with the family doctor and that she was available to discuss the health problems of all children, this would be a vast improvement on the present system. Since the doctor with a list of 3000 is likely to have about 500 schoolchildren on it, he may have to reduce the size of his list or seek the help of a health visitor-if the concept of care is to develop from being episodic to continuous. Once this is achieved, parents and children will have a far better health service. The need for a drive for dental.health remains and must be given high
priority for
many years to
come.
TODAY’S SOCIETY
Prosperity and a high standard of living have reduced the incidence of such common childhood conditions as malnutrition, rickets, or tuberculosis. Preventive and therapeutic advances have controlled such diseases as diphtheria or pneumonia. But there are still health hazards for the children of today and the citizens of tomorrow. In the past poverty prevented many parents from seeking medical advice at an early stage in a disease. The National Health Service has removed this barrier: difficulties caused by ignorance and custom remain. The programme for health education should be revised and extended so that parents are fully aware of their new responsibilities and know how they can obtain effective help. They should be taught to recognise the general practitioner as the leader of the domiciliary team, and be advised to consult him, or possibly the health visitor working with him, about all health problems that have not an important educational content. These should be the interest of the school doctor, who will act as a health counsellor to parents, pupils, and teachers and as a liaison between the school and the general practitioner, hospital, and specialist services. The school doctor’s role will be to keep an eye open for children who " fall by the wayside" because of parental apathy or ignorance or for any other reason. With the help of screening he will identify some defects, and with teachers, family doctors, and the hospital consultants help handicapped children with special needs. He must take an interest in the work of the school and he must be recognised as a member of the staff as this will help him to share in health education and secure the cooperation of the teachers. It does not really matter who gives a school child his booster doses against the communicable diseases, so long as the job is done. Though it would be preferable for them to be given by the family doctor, it will probably be necessary that the school doctor should give them for some time to come, so that herd immunity can be achieved.
The school doctor is sometimes described as a social at school with the remedies for the social conditions that make for ill health. But does it need a social physician, as well as a family doctor, to say that a child’s health would be improved if his family were rehoused ? To make a social diagnosis is not so difficult as to prescribe a treatment that can be practised, when so many factors are outside the control of the doctor. The practical details of how the school doctor can become a social physician have never been worked out adequately, nor has it been explained why this work should not be done by the family doctor. The pursuit of the ideal should not divert us from the solution
physician who seeks to link the findings
104
pressing practical problems. But it is clear that we afford the luxury of continuing to use antiquated procedures which are inefficient, no longer meet the needs of the times, and are wasteful in medical man-power. The school health service is one of the community health services and should be fully integrated with the others.
of
cannot
Egg and Salmonella people seldom share one
BECAUSE two hen’s egg, this source of salmonella infection remained unsuspected for a long time. Single cases of food-poisoning are seldom revealing. Eggs are infected most often by the hen which has laid them. The number of hens which harbour salmonellas-other than the avian serotypes which seldom cause human disease0is small. The chance of buying an infected shell egg among a dozen over the counter is minute, and the chance of buying two is negligible. It is only when eggs are bulked that their potential for causing infection becomes apparent. Bulking on a commercial scale means homogenisation, and a modem homogeniser will handle 40,000 eggs in an hour. One infected egg among these will, in theory at any rate, contaminate the whole batch. Duck eggs offer problems of their own. Far more ducks than hens are infected with salmonellas. Infection of the egg is probably more certain because it occurs in the bird’s cloaca. It was the relative rarity of duck eggs in our diet which drew attention to their dangers as long ago as 1926, but even now it is not unknown for a few to find their way into the homogenised
egg-mixture. was the dried egg for which we were so grateful durthe war which first suggested this as a source of ing salmonella infection. Since this import ceased, there has been increasing use of bulked whole eggs or egg products in the bakery and confectionery trades. They are easier to handle and to store, and, on a commercial scale, a good deal cheaper than shell eggs. Bulked eggs may take many forms. Eggs, home-produced or imported in shell, may be broken out, homogenised, and frozen. Eggs treated in the same way are imported already frozen from a dozen countries. Egg albumen is imported dried, and egg yolks too. At the bottom of the scale are the few dozen " seconds " cracked into a dirty bucket at the small packing-station and sold-with some stray feathers as a makeweight-to the local baker. Whatever their origin, the diligent bacteriologist will usually find a few samples containing salmonellas if he looks long enough.
It
with greater certainty to another batch of Chinese egg. From this, six strains of S. paratyphi, B were recovered, some which were of the same phage-type as those in the patients.2 Indeed, without the modern refinements of phage-typing, the painstaking inquiry into this and other egg-borne epidemics would have been far less fruitful, An illustration of the uses of this elegant method is given in a recent account of an egg-borne epidemic of foodpoisoning in and around Manchester which might serve as a model to others confronted with this problem.3 The egg in this instance was home-produced (and may have contained some duck eggs) and it is fair to say that, although Chinese egg products have been shown to contain far more salmonellas than those from other countries, every exporting country except one has sent us some unwanted salmonellas. The exception is Poland, where all liquid egg has been pasteurised for several years. We are told that several years of relentless nagging have been needed to move Whitehall to take any steps to protect the public from these dangers. Last autumn, however, regulations under the Food and Drugs Act (1955) were issued under which all liquid egg, whatever its origin, which is to be used for human food must be pasteurised as from New Year’s Day. So far as we know,4 the trade has accepted this responsibility in a sensible and cooperative way and we shall look to the annual returns of food-poisoning in the future for proof of its success. Social
Change
OPENING the British National Conference on Social Welfare in London last week,5 Mr. Quintin Hogg, Minister for Science, pointed to three central problems: the preservation of what was essentially good in civilisation in an age of restless, persistent, and accelerating change; the necessity to make perpetual adjustments and radical innovations in social and political machinery to take account of the continual changes in technical processes without outraging what was good and permanent in civilisation; and the need for political expertise and awareness in attaining these ends. Our communities were all mechanisms for the collective sustaining and enjoyment of man’s life as a social being. It was probably time to put into that task an amount of deliberate and informed social thinking and planning at least as great as the complex physical engineering effort that went into an aircraft cabin or the capsule of a rocket. Report. ibid. 1958, 17, 36. Essex-Cater, A. J., Jones, D. M., Swindell, F. J. Hyg. Lond. 196 61, 323. 4. S.I. 1963, no. 1503. 5. Times, Jan. 7. 2. 3.
Infectious Diseases in
England
In the Public Health Laboratory Service’s annual of food-poisoning, eggs have never appeared among the major causes; but they have never been absent from the list. Presumably most of the salmonellas in bulked egg are killed in the baking; but some of this material goes into custards or the viscid white compound now known as cream " which get little or no heating. Liquid egg is, moreover, sticky stuff which contaminates the bakehouse and its furniture only too easily. return
"
In 1954
a
suspicion
arose
that bulked egg
dangers greater than food-poisoning.1 The
might
carry
factor in some scattered cases of paratyphoid seemed to be a single batch of Chinese frozen egg. When examined in the laboratory this yielded several salmonella serotypes but no S. paratyphi B. A year later simultaneous cases of paratyphoid in Weymouth and Worthing could be attributed 1.
common
Newell, K. W. Mon. Bull. Minist. Hlth Lab. Serv. 1955, 14, 146.
*
Not
including
late returns.
and Wales
respiratory movements were possible and in no way hindered by the median sternotomy. Soon after operation I developed a nodal tachycardia with associated dyspnosa. Sinus rhythm was regained, however, during a four-week course of digoxin. Subjectively, dyspnoea and tachycardia are both very distressing symptoms, which merit careful investigation and treatment by the physician. By the fourth postoperative day I was able to sit up for a short while, and I was able to walk (with assistance at first) from the sixth day. full
Until the sixth week I had occasional bouts of
extra-
systoles, accompanied by transient feelings of faintness. The extrasystoles remitted without treatment, and for the past three months I have remained symptom-free. I should like
thank Prof. A. C. Dornhorst and Dr. Aubrey whose care I was and who have stimulated me to write this account. It is also a pleasure to record my debt to Dr. J. W. Kirklin and his team at the Mayo Clinic, Rochester, Minnesota, who kindlv undertook the ooerative closure of the lesion. St. George’s Hospital, to
Leatham, under
E. LETLEY
London, S.W.1
Public Health THE SCHOOL HEALTH SERVICE AND THE FAMILY DOCTOR BRIAN DIDSBURY M.B. Manc.,
D.P.H.,
D.P.A.
DEPUTY MEDICAL OFFICER OF HEALTH AND DEPUTY PRINCIPAL SCHOOL MEDICAL
OFFICER, WEST HAM
IT is natural for school doctors to take pride in the contribution their service has made to the health of children. But in each age and society methods of health promotion must be adjusted to changed circumstances and challenges. Our school medical service was designed at the beginning of this century to cope with conditions that no longer exist. It has largely continued on traditional lines, failing to take into account the improvement in child health in post-war Britain. Today 99 children out of every 100 examined at school are physically fit and every child has its own family doctor. Perhaps, therefore, many of the doctors and nurses working in the service (equivalent to more than 950 whole-time doctors and 2600 whole-time nurses) could now be employed more usefully elsewhere. In this paper I seek to redefine the role of the medical officer in the schools of today. THE WRONG
CHILD ?
Routine medical inspection of all schoolchildren was undoubtedly valuable in the early days of the service when many defects and diseases were detected and then treated. But nowadays the periodic inspections reveal comparatively few defects or diseases requiring treatment. The following are the figures for England and Wales in 1960-611 :
1. Based
on
the report of the Chief Medical Officer of the p. 233.
Education, 1960-61, table VIII,
Ministry of
School medical officers are required to record these defects or diseases " as requiring treatment " irrespective of whether the child is, or is not, under treatment at the time of examination. Moreover, the record fails to differentiate between the serious and the minor variations. Yet it is surely important to know the true incidence of serious defects and diseases and whether they are being treated. There are no national statistics for this, but the Chief Medical Officer’s report now has a small section on " defects not being treated ", based on inquiries conducted by three authorities. Apart from defects of vision and hearing, there is considerable truth in the criticism that the service is finding defects that have already been noted by family and hospital doctors and which are being treated. In 1961 2 million schoolchildren were examined at periodic medical inspections and over 720,000 at special inspections. Was this a useful expenditure of medical and nursing time ? Was it justified in terms of the disruption of classes and school routine ? The answer must be a qualified No. Because of the improvement in child health and the diagnostic and treatment facilities observed by the National Health Service, the school service should concentrate on selected children rather than dissipate its attention on the wholesale medical examination of all pupils. The need for a changed approach has long been appreciated by the Ministry of Education, but the response of the local authorities has been disappointing. The cautious experiments of the bolder authorities have more than justified the new methods. These vary from authority to authority, but the basic pattern consists of a health conference followed by the examination of selected
pupils. The nucleus of the conference is the head teacher, the nurse, supplemented if necessary by other persons, such as the class teacher or the school welfare officer. At the conference, the head teacher will bring forward the names of the pupils who have caused concern to the teaching staff by ill health, absence from school, or behaviour in class. The school nurse will suggest which children should have a medical examination based on her observations during vision testing, hygiene surveys, and contacts with their families, whom she meets in her other capacity as the district health visitor. The doctor will usually have looked at the children’s school and maternal and child-welfare health record cards. He may make a quick tour of the school to watch children at work and at play.
doctor, and the school
The virtue of such
scheme is that all the children are an enlarged health team which welcomes the teacher’s observations. More than the normal 6-7 minutes is allowed for the medical examination and consultation with the parent. The method has been used to replace the middle-school examination at 10 or 11 years, and as an alternative for school-leavers. There is no real reason why it should not be used in infant schools. The maternal and child-welfare records should be helpful with this age-group and the health-visitor/school-nurse should know " her children ’’ and " her homes ". But it is not a substitute for screening tests of vision and hearing. Unfortunately few authorities have sought the views of the general practitioners about the children selected for examination. This is a pity because in general practice it is practically impossible not to know a family with young children, if they have been on " the list " for any length of time. With the new method the number of referrals is at first rather high, but with experience it tends to settle down to a more reasonable a
regularly considered by
102
Some authorities have made their task difficult by trying to select all pupils with any form of health problem instead of concentrating on those who have a problem which might affect their education. Once this division of labour is accepted, the new approach could be applied to all schools and save both educational and medical time.
rate.
THE WRONG
DOCTOR?
There has been a growing tendency to integrate the work of the school medical officer and the doctors of the maternal -and child-welfare services. This has been welcomed by the younger assistant medical officers because it has brought interest and variety to their work. The claim has also been made that it ensures continuous health supervision from infancy to adolescence. The important question which is usually avoided is whether the wrong doctor is doing the supervision-i.e., should not this be the role of the family practitioner rather than of the local-authority medical officers ? If we stop thinking of children as individuals and consider them as members of a family group, it will be obvious that the general practitioner is in a unique position to promote health. The family doctor who is interested in the early detection of disease in children, in the simple dynamics of health and sickness in the home, and in trying to ensure the health of the individual child is a first-rate practitioner of preventive medicine. Such doctors are not " rare birds ". The younger doctors in the public-health service and in general practice are not interested in the old antagonisms and feuds of the pre-1948 era. The climate is now favourable for a changed relationship as far as the school health service is concerned.
This does not mean that the general practitioner should carry out medical inspections in the school, nor sit in a school clinic or in his own surgery examining schoolchildren. But as a good family doctor he will extend his interest in his patients beyond episodes of illness. Parents should be told that if they are worried about their child’s health they should consult their family doctor in the first place. If the problem is likely to affect the child’s education, he will consult the school doctor, who should specialise in educational problems and not act as a convenient second opinion for the parent who does not trust her own doctor. The family doctor cannot observe the child in the school setting, and it would be unreasonable to ask him to test children’s vision or to make audiometric surveys. These investigations can be done by others and significant results brought to his attention by the school doctor. WRONG
TECHNIQUES
The periodic medical inspection is not a particularly efficient technique. Leeconcluded that only 60% of the defects which caused the rejection of young men for military service were noted on the record cards of the school health service. The Chief Medical Officer’s report reveals that in 1956 for every thousand children examined school entrants " 2 had squints in Halifax and 107 in as Stockport; 0-5 had discharging ears in West Ham and 109 in Salford; 1-4 had, or were suspected of having, heart-disease in Warrington and 50 in Burton-on-Trent and in Northampton; 0-8 had a hernia in Doncaster and "
2.
Lee, J. A. H. Brit. med. J. 1958, i, 573.
28 in Smethwick; 3 had " lung disease " in Cheshire and 124 in Dudley. In these circumstances, it might be better to examine thoroughly a representative sample of schoolchildren to provide national norms. Moreover, it is far less important to know the exact incidence of otitis media in schoolchildren than to be sure_that their parents will seek medical advice promptly. Otitis media can develop very quickly: at child may not been seen by the school doctor for several years under the present system of
periodic medical inspections. The chief safeguard of a child’s health is the education of his parents. Can we honestly say that a vigorous and effective attempt has been made to educate the public about the early signs and symptoms of diseases which affect schoolchildren or to encourage them to think of their family doctor not only as the person they consult when a child is ill but also about all health problems? Many authorities who have introduced the new method of health surveillance send a health questionnaire to all the parents and invite them to see the school doctor if they are worried about their child’s health. In these ways the authority fails to build up the image of the family doctor as a health expert. Minor-ailment clinics and artificial-light clinics are also anachronisms. The regular patrons of minor-ailment clinics come from nearby schools, yet the health of the children in the most distant schools seems unaffected, nor do the head teachers complain that pupils have difficulty in obtaining medical care. Another useless task of the school doctor is the medical examination of children who want to be errand boys or deliver newspapers. 2770 children were examined in Manchester in 1958 for " fitness for employment " and only 2 were considered unfit. Selection could obviously be introduced here with
profit. These anachronisms leave the school doctor neither time nor opportunity to make an effective contribution to health education, or to come to grips with the real problems of the modern child. Can anybody be happy about the tragedies that follow promiscuous sexual activities among teenagers ? What is the life expectation of the overweight school child ? Is the prognosis for the heavy teenage smoker more encouraging ? Other questions spring to mind which demand research and an organised multidisciplinary approach. 66 local educational authorities in England and Wales have child populations of less than 20,000 each. If school medical officers are shorn of their responsibility for the normal child and if the trend to specialisation continues-e.g., the medical and educational problems of the deaf child-some officers could be shared on a regional basis to carry out special investigations without regard to local-authority boundaries. TEACHER’S
VIEWPOINT
The teacher’s attitude towards the school health service is ambivalent. He appreciates that protracted illness or poor health is likely to hinder a child’s educational progress, but he would like it to be recognised in practice as well as in theory that the prime function of a school is education. At times the teacher feels that his school has become a too convenient appendage of the health department. In a short period a school can receive visits from a doctor for medical inspections and then for immunisa-
tions ; from a nurse for hygiene surveys and then for vision-testing; from an audiometrician; and, if it is very fortunate, from a dentist. Class work is interrupted,
103
programme and routine have to be adjusted, and the results are not always tangible. Matters are not improved if the members of the health team-and this unfortunately usually means the doctor-are not punctual or fail to establish a good relation with the headteacher. A real advantage of the newer methods that are replacing the periodic medical inspection is that they make the teacher a vital member of the school health team, and teachers welcome this new form of constructive
partnership. THE CHILDREN .
The service deals with three types of children: handicapped pupils, children with defects, and normal children.
Handicapped Children Out of a school population of 7 million,some 70,000 attend day or residential special schools for handicapped " pupils. Most of these children are described as educationally subnormal ". (They include dull and backward children, but not those whose intelligence quotient is under 50 who are usually trained outside the educational system.) The doctor’s main contribution to the training of these children is diagnosis of their handicap; some will need the help of a consultant. Close cooperation and teamwork between educationalists and doctors with special knowledge is needed if the handicapped pupil’s remaining talents and skills are to be developed to the full. This type of knowledge can be acquired by a family doctor. His other work may not allow him to find time for the necessary training, but when he can his relative permanency provides useful continuity. Children with
Defects
The needs of the child with a defect are rather different. Where the handicapped child’s chief medical needs are continuity in care and supervision, his are early diagnosis and prompt remedial action. Screening tests are essential for early detection of visual and hearing defects. Further experience is needed to evaluate mental-health screening tests. If they are to be generally adopted, it will be necessary to use the teacher’s ability to observe and assess the children in class, and she will need help and counsel from either the school doctor or nurse. At this stage it would be wrong to base our mental-health programme for schoolchildren on a search for mental pathology in every facet of behaviour. Child-guidance clinics are already overburdened and it would be sensible to make more use of the family doctor’s talents. It is, of course, easier to persuade a mother to give her child oral penicillin than to adopt a less rigid attitude towards the child who fails to conform to her concept of normality or acceptable behaviour. But the family doctor, because of his knowledge of the home, is in a better position to do this than the school medical officer. Only when the school situation is important need the local-authority medical officer be drawn in. Direct contact between the general practitioner and the class teacher is theoretically possible but is unlikely to be close. The link between him and the teacher should be the school doctor or possibly, and this may be better, the health visitor or school nurse, particularly if the health visitor is linked with the practice rather than based on a clinic. Normal Children
The link between the school and the family doctor should be strengthened also for normal children. If
parents knew that their health visitor was working in close cooperation with the family doctor and that she was available to discuss the health problems of all children, this would be a vast improvement on the present system. Since the doctor with a list of 3000 is likely to have about 500 schoolchildren on it, he may have to reduce the size of his list or seek the help of a health visitor-if the concept of care is to develop from being episodic to continuous. Once this is achieved, parents and children will have a far better health service. The need for a drive for dental.health remains and must be given high
priority for
many years to
come.
TODAY’S SOCIETY
Prosperity and a high standard of living have reduced the incidence of such common childhood conditions as malnutrition, rickets, or tuberculosis. Preventive and therapeutic advances have controlled such diseases as diphtheria or pneumonia. But there are still health hazards for the children of today and the citizens of tomorrow. In the past poverty prevented many parents from seeking medical advice at an early stage in a disease. The National Health Service has removed this barrier: difficulties caused by ignorance and custom remain. The programme for health education should be revised and extended so that parents are fully aware of their new responsibilities and know how they can obtain effective help. They should be taught to recognise the general practitioner as the leader of the domiciliary team, and be advised to consult him, or possibly the health visitor working with him, about all health problems that have not an important educational content. These should be the interest of the school doctor, who will act as a health counsellor to parents, pupils, and teachers and as a liaison between the school and the general practitioner, hospital, and specialist services. The school doctor’s role will be to keep an eye open for children who " fall by the wayside" because of parental apathy or ignorance or for any other reason. With the help of screening he will identify some defects, and with teachers, family doctors, and the hospital consultants help handicapped children with special needs. He must take an interest in the work of the school and he must be recognised as a member of the staff as this will help him to share in health education and secure the cooperation of the teachers. It does not really matter who gives a school child his booster doses against the communicable diseases, so long as the job is done. Though it would be preferable for them to be given by the family doctor, it will probably be necessary that the school doctor should give them for some time to come, so that herd immunity can be achieved.
The school doctor is sometimes described as a social at school with the remedies for the social conditions that make for ill health. But does it need a social physician, as well as a family doctor, to say that a child’s health would be improved if his family were rehoused ? To make a social diagnosis is not so difficult as to prescribe a treatment that can be practised, when so many factors are outside the control of the doctor. The practical details of how the school doctor can become a social physician have never been worked out adequately, nor has it been explained why this work should not be done by the family doctor. The pursuit of the ideal should not divert us from the solution
physician who seeks to link the findings
104
pressing practical problems. But it is clear that we afford the luxury of continuing to use antiquated procedures which are inefficient, no longer meet the needs of the times, and are wasteful in medical man-power. The school health service is one of the community health services and should be fully integrated with the others.
of
cannot
Egg and Salmonella people seldom share one
BECAUSE two hen’s egg, this source of salmonella infection remained unsuspected for a long time. Single cases of food-poisoning are seldom revealing. Eggs are infected most often by the hen which has laid them. The number of hens which harbour salmonellas-other than the avian serotypes which seldom cause human disease0is small. The chance of buying an infected shell egg among a dozen over the counter is minute, and the chance of buying two is negligible. It is only when eggs are bulked that their potential for causing infection becomes apparent. Bulking on a commercial scale means homogenisation, and a modem homogeniser will handle 40,000 eggs in an hour. One infected egg among these will, in theory at any rate, contaminate the whole batch. Duck eggs offer problems of their own. Far more ducks than hens are infected with salmonellas. Infection of the egg is probably more certain because it occurs in the bird’s cloaca. It was the relative rarity of duck eggs in our diet which drew attention to their dangers as long ago as 1926, but even now it is not unknown for a few to find their way into the homogenised
egg-mixture. was the dried egg for which we were so grateful durthe war which first suggested this as a source of ing salmonella infection. Since this import ceased, there has been increasing use of bulked whole eggs or egg products in the bakery and confectionery trades. They are easier to handle and to store, and, on a commercial scale, a good deal cheaper than shell eggs. Bulked eggs may take many forms. Eggs, home-produced or imported in shell, may be broken out, homogenised, and frozen. Eggs treated in the same way are imported already frozen from a dozen countries. Egg albumen is imported dried, and egg yolks too. At the bottom of the scale are the few dozen " seconds " cracked into a dirty bucket at the small packing-station and sold-with some stray feathers as a makeweight-to the local baker. Whatever their origin, the diligent bacteriologist will usually find a few samples containing salmonellas if he looks long enough.
It
with greater certainty to another batch of Chinese egg. From this, six strains of S. paratyphi, B were recovered, some which were of the same phage-type as those in the patients.2 Indeed, without the modern refinements of phage-typing, the painstaking inquiry into this and other egg-borne epidemics would have been far less fruitful, An illustration of the uses of this elegant method is given in a recent account of an egg-borne epidemic of foodpoisoning in and around Manchester which might serve as a model to others confronted with this problem.3 The egg in this instance was home-produced (and may have contained some duck eggs) and it is fair to say that, although Chinese egg products have been shown to contain far more salmonellas than those from other countries, every exporting country except one has sent us some unwanted salmonellas. The exception is Poland, where all liquid egg has been pasteurised for several years. We are told that several years of relentless nagging have been needed to move Whitehall to take any steps to protect the public from these dangers. Last autumn, however, regulations under the Food and Drugs Act (1955) were issued under which all liquid egg, whatever its origin, which is to be used for human food must be pasteurised as from New Year’s Day. So far as we know,4 the trade has accepted this responsibility in a sensible and cooperative way and we shall look to the annual returns of food-poisoning in the future for proof of its success. Social
Change
OPENING the British National Conference on Social Welfare in London last week,5 Mr. Quintin Hogg, Minister for Science, pointed to three central problems: the preservation of what was essentially good in civilisation in an age of restless, persistent, and accelerating change; the necessity to make perpetual adjustments and radical innovations in social and political machinery to take account of the continual changes in technical processes without outraging what was good and permanent in civilisation; and the need for political expertise and awareness in attaining these ends. Our communities were all mechanisms for the collective sustaining and enjoyment of man’s life as a social being. It was probably time to put into that task an amount of deliberate and informed social thinking and planning at least as great as the complex physical engineering effort that went into an aircraft cabin or the capsule of a rocket. Report. ibid. 1958, 17, 36. Essex-Cater, A. J., Jones, D. M., Swindell, F. J. Hyg. Lond. 196 61, 323. 4. S.I. 1963, no. 1503. 5. Times, Jan. 7. 2. 3.
Infectious Diseases in
England
In the Public Health Laboratory Service’s annual of food-poisoning, eggs have never appeared among the major causes; but they have never been absent from the list. Presumably most of the salmonellas in bulked egg are killed in the baking; but some of this material goes into custards or the viscid white compound now known as cream " which get little or no heating. Liquid egg is, moreover, sticky stuff which contaminates the bakehouse and its furniture only too easily. return
"
In 1954
a
suspicion
arose
that bulked egg
dangers greater than food-poisoning.1 The
might
carry
factor in some scattered cases of paratyphoid seemed to be a single batch of Chinese frozen egg. When examined in the laboratory this yielded several salmonella serotypes but no S. paratyphi B. A year later simultaneous cases of paratyphoid in Weymouth and Worthing could be attributed 1.
common
Newell, K. W. Mon. Bull. Minist. Hlth Lab. Serv. 1955, 14, 146.
*
Not
including
late returns.
and Wales