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WHITHER MEDICINE ?
451
Special Articles
SCHOOL MEALS
In Bogota the catering for school meals has been let out to -contractors, and I was able to see a copy of the contract. This was a remarkable document. Detailed day-to-day menus were laid down, but for -very few items were the quantities specified. Thus on certain days the children were to get a cup of cocoa with milk, a plate of rice with meat and vegetables, and so on. The Nutrition Institute, analysing samples of the ensuing meals, has found that sometimes as much as 80% of the calories was provided by carbohydrate. The city of Medellin, with 30,000 school-children, is a great contrast in this respect to the capital. Here 2000 midday meals are provided free for necessitous children. The food is prepared in a single centre and sent out to schools. I saw one meal ; it consisted of 500 ml. of milk (pasteurised and clearly with a high fat content), a large whole-wheat sandwich with a slice of meat, a slice of tomato and a little cabbage, an orange, and a lump of unrefined sugar. In the whole country 55,000 children are reported to receive, school meals. Neither the diet scales nor the administration are standardised. Medellin and Bogota are probably examples of the extremes of effectiveness of the schemes. CHILDREN’S ORGANISATIONS In 1945 Colombia had 58 Gotas de Leche (infant centres), 30 day nurseries, 5 milk centres, 85 clinics for healthy children, 120 clinics for sick children, 15 children’s hospitals, and 7 children’s gardens. Nearly 90,000 children attended these institutions and over 3 million bottles of milk were distributed. Most of the milk is distributed by the Gotas de Leche, and the one I saw in operation was issuing a milk-sugar-flour mixture for infants one to two years old. The preparation and distribution of the bottles was in the hands of conscientious Catholic sisters. The composition of the mixture varied from day to day, but usually each bottle contained 200 ml. The Gotas de Leche are a private organisation, but receive some financial support from the government.
At these institutions, in 1945, 38,000 children were smallpox and 10,000 against diphtheria and other bacterial disease. Neither the immunisation nor the feeding services can in any way cover the needs of the children : the majority never come within their scope. My last morning’s observations in South America illustrate the difficulties in judging children’s services.
immunised against
I
was
first taken
provincial capital separate building
by
municipal public-health staff of a hospital. This is a main hospital group, with accomThe building is modern and struc-
the
to visit the children’s
in the modation for 130 beds. turally good. There is an isolation ward with about 20 beds. In this ward, in which there were no separate cubicles, there were patients reputed to be suffering from chickenpox, meningitis, Vincent’s angina, typhoid, typhus, whooping-cough, measles, and gastro-enteritis. There appears to be no
bacteriological
or serological diagnostic service, so accurate impossible, but I certainly heard whoops and saw a measles rash and some pocks. Those children that were not confined to bed were playing around together. The whole ward was a complete medical muddle-if not a public scandal. Then I was put in a car and driven 10 miles to a holiday home for schoolgirls, which takes 100 girls for three months
diagnosis
was
on medical recommendation.
The home is in a well-built two-storied house round a central courtyard. It is in a beautiful countryside and has a large garden with prolific vegetable crops. There is a fine swimming-bath, a good kitchen, a laundry, and a sick-bay. The house was spotlessly clean and the two women in charge were clearly competent and enthusiastic. The girls looked well and happy. Any municipality in the world would be glad to own this beautiful home and could admire its administration.
It is contrasts like these-so frequent in all the about countries visited-that make generalisation children’s health services so impossible.
WHITHER MEDICINE ? THIS was the title of an address by LORD HORDER to the- West London Medico-Chirurgical Society ’on Feb. 18. A man from Mars, he said, would think the
question unintelligent. Whither, indeed, except straight forging more weapons, taking more toll of science in the interests of mankind, adding more and more culture to more and more learning. He would poin’t out that medicine had already dealt, not unsuccessfully, with the simpler and grosser causes of bodily disablement, thatrnen no longer died in swathes as a result of plague, smallpox, or typhoid fever, and that life had been lengthened. But he would also discover many victims of what was called high blood-pressure and cardiovascular degeneration ; he would find no lessening of psychoneuroses, and, as for the spirit of man rather than the body, he would say that we had not yet begun to develop that. Today there had been opened for the- statesman, the sociologist, and the doctor a large field for inquiry and action. The medical man could not neglect that field ; he must take his part in it, though he must not spend in it the whole of his time. He must’get apart like Harvey, when he walked up and down under the trees of Combe, thinking. He must not get absorbed amd lost in what the statesman and the sociologist happened to be thinking at the moment. They were opportunists-; medicine was permanent. To stand aloof from the work that was going on in this field was to do a disservice not only to society but to medicine itself, and yet to become entirely absorbed in it was to do an even greater disservice. Supposing medicine was given the chance of helping the State by making constructive suggestions, what Granted that certain would those suggestions be ? basic desiderata were forthcoming-namely, that medical services were equipped to provide everything that, science could offer for the preservation of health and the cure of on,
disease-these must be made available to the entire The public should be encouraged to take a vital interest in the plans for its health and happiness and be represented in the formulation of such plans’; but inasmuch as it was the doctor who must render these medical services, he should play the dominant r6le. Quality in medical service must be preserved. Adequate hospital facilities, with professional and non-professional personnel, must be available before the scheme came into operation, instead of trusting to a lucky hazard that all these would arrive later on. Finally, Government help, preferably by grants-in-aid, would be necessary. Some method of grants-in-aid seemed to offer the greatest promise because only by that method could the citizen be kept " on his toes " in respect of his own health. But medicine would have failed in an important part of its duty if it did not warn the State that if the more basic needs of the citizen were not met, the direct contribution of medicine would avail little. By " basic needs " he meant proper food, suitable shelter, a satisfactory job of work, fresh air and sun, and reasonable leisure for the enjoyment of the amenities of life. And that was the State’s job. In his closing passages Lord Horder touched allusively upon recent events. It almost seemed, he said, as though
population.
’
doctors were becoming politicians by force majeure. Osler, he thought, would have resisted any allurement of politics : he would have ordered his sailors to bind him to the mast until the danger was over. An attitude of calm detachment would have characterised him. It was paramount that medicine should remain detached from political clamour on the Left or the Right. For medicine there could be no Left or Right, only the seeking of expert knowledge and adherence to the truth. I have seemed sententious " If," said Lord Horder, I crave forgiveness, but here is something to be sententious about. I have spent a long life in the service of medicine. If I have one regret it is a personal one, that I have fallen very short of my own ideals. But my allegiance to medicine is a sort of conditioned reflex. I can do no other, so help me, God ! And I will continue to serve medicine, shoulder to shoulder with those colleagues who have seen the same vision and followed the same gleam." "
Special Articles
SCHOOL MEALS
In Bogota the catering for school meals has been let out to -contractors, and I was able to see a copy of the contract. This was a remarkable document. Detailed day-to-day menus were laid down, but for -very few items were the quantities specified. Thus on certain days the children were to get a cup of cocoa with milk, a plate of rice with meat and vegetables, and so on. The Nutrition Institute, analysing samples of the ensuing meals, has found that sometimes as much as 80% of the calories was provided by carbohydrate. The city of Medellin, with 30,000 school-children, is a great contrast in this respect to the capital. Here 2000 midday meals are provided free for necessitous children. The food is prepared in a single centre and sent out to schools. I saw one meal ; it consisted of 500 ml. of milk (pasteurised and clearly with a high fat content), a large whole-wheat sandwich with a slice of meat, a slice of tomato and a little cabbage, an orange, and a lump of unrefined sugar. In the whole country 55,000 children are reported to receive, school meals. Neither the diet scales nor the administration are standardised. Medellin and Bogota are probably examples of the extremes of effectiveness of the schemes. CHILDREN’S ORGANISATIONS In 1945 Colombia had 58 Gotas de Leche (infant centres), 30 day nurseries, 5 milk centres, 85 clinics for healthy children, 120 clinics for sick children, 15 children’s hospitals, and 7 children’s gardens. Nearly 90,000 children attended these institutions and over 3 million bottles of milk were distributed. Most of the milk is distributed by the Gotas de Leche, and the one I saw in operation was issuing a milk-sugar-flour mixture for infants one to two years old. The preparation and distribution of the bottles was in the hands of conscientious Catholic sisters. The composition of the mixture varied from day to day, but usually each bottle contained 200 ml. The Gotas de Leche are a private organisation, but receive some financial support from the government.
At these institutions, in 1945, 38,000 children were smallpox and 10,000 against diphtheria and other bacterial disease. Neither the immunisation nor the feeding services can in any way cover the needs of the children : the majority never come within their scope. My last morning’s observations in South America illustrate the difficulties in judging children’s services.
immunised against
I
was
first taken
provincial capital separate building
by
municipal public-health staff of a hospital. This is a main hospital group, with accomThe building is modern and struc-
the
to visit the children’s
in the modation for 130 beds. turally good. There is an isolation ward with about 20 beds. In this ward, in which there were no separate cubicles, there were patients reputed to be suffering from chickenpox, meningitis, Vincent’s angina, typhoid, typhus, whooping-cough, measles, and gastro-enteritis. There appears to be no
bacteriological
or serological diagnostic service, so accurate impossible, but I certainly heard whoops and saw a measles rash and some pocks. Those children that were not confined to bed were playing around together. The whole ward was a complete medical muddle-if not a public scandal. Then I was put in a car and driven 10 miles to a holiday home for schoolgirls, which takes 100 girls for three months
diagnosis
was
on medical recommendation.
The home is in a well-built two-storied house round a central courtyard. It is in a beautiful countryside and has a large garden with prolific vegetable crops. There is a fine swimming-bath, a good kitchen, a laundry, and a sick-bay. The house was spotlessly clean and the two women in charge were clearly competent and enthusiastic. The girls looked well and happy. Any municipality in the world would be glad to own this beautiful home and could admire its administration.
It is contrasts like these-so frequent in all the about countries visited-that make generalisation children’s health services so impossible.
WHITHER MEDICINE ? THIS was the title of an address by LORD HORDER to the- West London Medico-Chirurgical Society ’on Feb. 18. A man from Mars, he said, would think the
question unintelligent. Whither, indeed, except straight forging more weapons, taking more toll of science in the interests of mankind, adding more and more culture to more and more learning. He would poin’t out that medicine had already dealt, not unsuccessfully, with the simpler and grosser causes of bodily disablement, thatrnen no longer died in swathes as a result of plague, smallpox, or typhoid fever, and that life had been lengthened. But he would also discover many victims of what was called high blood-pressure and cardiovascular degeneration ; he would find no lessening of psychoneuroses, and, as for the spirit of man rather than the body, he would say that we had not yet begun to develop that. Today there had been opened for the- statesman, the sociologist, and the doctor a large field for inquiry and action. The medical man could not neglect that field ; he must take his part in it, though he must not spend in it the whole of his time. He must’get apart like Harvey, when he walked up and down under the trees of Combe, thinking. He must not get absorbed amd lost in what the statesman and the sociologist happened to be thinking at the moment. They were opportunists-; medicine was permanent. To stand aloof from the work that was going on in this field was to do a disservice not only to society but to medicine itself, and yet to become entirely absorbed in it was to do an even greater disservice. Supposing medicine was given the chance of helping the State by making constructive suggestions, what Granted that certain would those suggestions be ? basic desiderata were forthcoming-namely, that medical services were equipped to provide everything that, science could offer for the preservation of health and the cure of on,
disease-these must be made available to the entire The public should be encouraged to take a vital interest in the plans for its health and happiness and be represented in the formulation of such plans’; but inasmuch as it was the doctor who must render these medical services, he should play the dominant r6le. Quality in medical service must be preserved. Adequate hospital facilities, with professional and non-professional personnel, must be available before the scheme came into operation, instead of trusting to a lucky hazard that all these would arrive later on. Finally, Government help, preferably by grants-in-aid, would be necessary. Some method of grants-in-aid seemed to offer the greatest promise because only by that method could the citizen be kept " on his toes " in respect of his own health. But medicine would have failed in an important part of its duty if it did not warn the State that if the more basic needs of the citizen were not met, the direct contribution of medicine would avail little. By " basic needs " he meant proper food, suitable shelter, a satisfactory job of work, fresh air and sun, and reasonable leisure for the enjoyment of the amenities of life. And that was the State’s job. In his closing passages Lord Horder touched allusively upon recent events. It almost seemed, he said, as though
population.
’
doctors were becoming politicians by force majeure. Osler, he thought, would have resisted any allurement of politics : he would have ordered his sailors to bind him to the mast until the danger was over. An attitude of calm detachment would have characterised him. It was paramount that medicine should remain detached from political clamour on the Left or the Right. For medicine there could be no Left or Right, only the seeking of expert knowledge and adherence to the truth. I have seemed sententious " If," said Lord Horder, I crave forgiveness, but here is something to be sententious about. I have spent a long life in the service of medicine. If I have one regret it is a personal one, that I have fallen very short of my own ideals. But my allegiance to medicine is a sort of conditioned reflex. I can do no other, so help me, God ! And I will continue to serve medicine, shoulder to shoulder with those colleagues who have seen the same vision and followed the same gleam." "