2
87 production of thyrotropic hormone. Thyrotoxic patients treated with radio-iodine may therefore be exposed to a greater risk of carcinogenesis than they would be with either subtotal thyroidectomy or the antithyroid drugs, which have no specific carcinogenic action. Those using radio-iodine are well aware of this theoretical danger and therefore tend to restrict its use to carefully selected, and usually elderly patients. In such cases the complete absence of immediate complications justifies the remote and so far hypothetical risk. One further practical point emerges from DONIACH’S work. He showed that in the rat one dose of radio- iodine, followed by a course of methyl-thiouracil, is a particularly effective method of producing thyroid tumours. Yet the clinician may be tempted to employ this very sequence. When a severely thyrotoxic patient, judged unfit for operation, is treated with radio-iodine the response is apt to be slow and uncertain (though it is always effective in the end) ; and doses may have to be repeated for perhaps a year. Meanwhile the patient remains very ill, and the physician may thus advise thiouracil while waiting for the radio-iodine to act. With the laboratory evidence before us, this seems an altogether unjustified risk. 0 Tasks for the M.O.H. THE cost of revolution must be counted long after the event, and we still stand too close to July 5, 1948, to be able to measure accurately either gains or losses. Much has been heard of the changes it has wrought in general practice, but not enough, perhaps, about its effect on the local-government public-health service. This product of a century’s growth stood four-square and apparently durable for all time ; but today even the need for its existence is being called in question by some. Admittedly, preoccupation with the provision of hospital services sometimes lessened the attention given by local health authorities to their primary function of prevent- ing disease and promoting health ; but the removal of these hospital and clinical interests was undoubtedly a severely traumatic change : a patient may bleed to death after removal of a tumour as well as after removal of a vital limb. In certain directions the powers of the authorities have been increased by the Act, and there is still no country where organised public health has wider powers or more universal machinery. But within the structure there are signs of deterioration : loss of interest on the part of local representatives is shown by a fall in the quality of membership of health committees ; loss of a sense of purpose and direction on the part of local officials, and especially the medical officer of health, is shown in a common sense of frustration and in a falling away of recruitment to the service. What now seems necessary, if the situation is to be saved, is a careful study to determine the jobs which the public-health services can do better than anyone else, and a determination that they shall have the necessary power and backing to perform these tasks. The National Health Service in Scotland is a trimmer ship than the much larger service in England and Wales ; so it was not surprising that the Scots should turn their attention earlier to the difficult position of the local health authorities and their medical officers of health. Having had indications in the recent report of the Department of Health for ’Scotland,’ we now have the results of a committee inquiry published under the title, What Local Authorities can do to promote Health and Prevent Disease.2 Perhaps hopes aroused by such a title were bound to be disappointed in some measure ; and there are parts of this report which read as though its authors had sat round a table to compile a list of all possible ways in which disease prevention and health promotion might conceivably be furthered. Certainly it is well to remind ourselves from time to time just how much work there is still to be done ; but many of the outstanding tasks call for more staff and more machinery, and for new skills as well ; and a covering note from the Department of Health for Scotland speaks of the need for strict economy and of shortage of staff. In economic terms the priority accorded to local health authorities under the National Health Service can be judged from the fact that in Scotland during the last financial year their services accounted for about a fortieth of the total Government expenditure on the National Health Service and only about a twenty-fifth of the cost of the hospital service. The committee goes on to emphasise the need for research and statistical inquiry in public-health work. The objective is laudable, but the difficulties are great. Fifty years ago simple vital statistics gave a clear lead to useful action ; but not today. Thus among the subjects that the committee recom- mends for study are accidents, rheumatism, peptic ulcer, and heart-disease ; and health-authority records and administration are not usually designed to permit difficult investigations of this sort. It is not fortuitous that, with some notable exceptions, little research has come from the public-health service in the last few decades: the service has simply not developed along lines that encourage research. One field where hard thinking is urgently needed is the relation of the local health authorities to the other components of the health service. If the medical officer of health is meant to act as the coördinator—as he is sometimes told-then his position should be left in no doubt; it should not be left to the chance of personalities. Fortunately the National Health Service has helped to bring together the medical officer of health and the general practi- tioner, who formerly seemed to face each other as rivals across the maternity and child-welfare services. The opportunities for collaboration have been greatly enlarged now that the local health authority must provide health visitors, midwives, district nurses, and home helps, all of whom can directly aid the family doctor. How, in return, the practitioner is to contribute more to preventive medicine is uncertain. Many local health authorities have tried inviting practitioners to participate in the work of antenatal and child-welfare clinics, and in school health work; but it is not always easy to reconcile the punctual attendance necessary for such work with the busy and irregular day of general practice. It seems that the general practitioner should be ideally placed for 1. Reports of the Department of Health for Scotland and the Scottish Health Services Council, 1950. H.M. Stationery Office, 1951. 2. What Local Authorities can do to promote Health and Prevent Disease. H.M. Stationery Office, 1951.

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87

production of thyrotropic hormone. Thyrotoxicpatients treated with radio-iodine may therefore beexposed to a greater risk of carcinogenesis than theywould be with either subtotal thyroidectomy or theantithyroid drugs, which have no specific carcinogenicaction. Those using radio-iodine are well aware ofthis theoretical danger and therefore tend to restrictits use to carefully selected, and usually elderlypatients. In such cases the complete absence ofimmediate complications justifies the remote and sofar hypothetical risk.One further practical point emerges from DONIACH’S

work. He showed that in the rat one dose of radio-iodine, followed by a course of methyl-thiouracil,is a particularly effective method of producing thyroidtumours. Yet the clinician may be tempted to employthis very sequence. When a severely thyrotoxicpatient, judged unfit for operation, is treated withradio-iodine the response is apt to be slow anduncertain (though it is always effective in the end) ; anddoses may have to be repeated for perhaps a year.Meanwhile the patient remains very ill, and the

physician may thus advise thiouracil while waitingfor the radio-iodine to act. With the laboratoryevidence before us, this seems an altogether unjustifiedrisk. 0

Tasks for the M.O.H.THE cost of revolution must be counted long

after the event, and we still stand too close to July 5,1948, to be able to measure accurately either gainsor losses. Much has been heard of the changes ithas wrought in general practice, but not enough,perhaps, about its effect on the local-governmentpublic-health service. This product of a century’sgrowth stood four-square and apparently durablefor all time ; but today even the need for its existenceis being called in question by some. Admittedly,preoccupation with the provision of hospital servicessometimes lessened the attention given by localhealth authorities to their primary function of prevent-ing disease and promoting health ; but the removalof these hospital and clinical interests was undoubtedlya severely traumatic change : a patient may bleedto death after removal of a tumour as well as afterremoval of a vital limb. In certain directions the

powers of the authorities have been increased by theAct, and there is still no country where organisedpublic health has wider powers or more universal

machinery. But within the structure there are

signs of deterioration : loss of interest on the partof local representatives is shown by a fall in the

quality of membership of health committees ; lossof a sense of purpose and direction on the part oflocal officials, and especially the medical officer ofhealth, is shown in a common sense of frustration andin a falling away of recruitment to the service. Whatnow seems necessary, if the situation is to be saved,is a careful study to determine the jobs which thepublic-health services can do better than anyoneelse, and a determination that they shall have thenecessary power and backing to perform these tasks.The National Health Service in Scotland is a trimmer

ship than the much larger service in England andWales ; so it was not surprising that the Scots shouldturn their attention earlier to the difficult positionof the local health authorities and their medical

officers of health. Having had indications in therecent report of the Department of Health for’Scotland,’ we now have the results of a committeeinquiry published under the title, What LocalAuthorities can do to promote Health and PreventDisease.2 Perhaps hopes aroused by such a title werebound to be disappointed in some measure ; andthere are parts of this report which read as thoughits authors had sat round a table to compile a listof all possible ways in which disease prevention andhealth promotion might conceivably be furthered.

Certainly it is well to remind ourselves from time totime just how much work there is still to be done ;but many of the outstanding tasks call for more staffand more machinery, and for new skills as well ;and a covering note from the Department of Healthfor Scotland speaks of the need for strict economyand of shortage of staff. In economic terms thepriority accorded to local health authorities underthe National Health Service can be judged from thefact that in Scotland during the last financial yeartheir services accounted for about a fortieth ofthe total Government expenditure on the NationalHealth Service and only about a twenty-fifth ofthe cost of the hospital service.The committee goes on to emphasise the need for

research and statistical inquiry in public-healthwork. The objective is laudable, but the difficultiesare great. Fifty years ago simple vital statistics

gave a clear lead to useful action ; but not today.Thus among the subjects that the committee recom-mends for study are accidents, rheumatism, pepticulcer, and heart-disease ; and health-authorityrecords and administration are not usually designedto permit difficult investigations of this sort. It isnot fortuitous that, with some notable exceptions,little research has come from the public-health servicein the last few decades: the service has simply notdeveloped along lines that encourage research.One field where hard thinking is urgently needed

is the relation of the local health authorities tothe other components of the health service. If themedical officer of health is meant to act as thecoördinator—as he is sometimes told-then his

position should be left in no doubt; it should not beleft to the chance of personalities. Fortunately theNational Health Service has helped to bring togetherthe medical officer of health and the general practi-tioner, who formerly seemed to face each other asrivals across the maternity and child-welfare services.The opportunities for collaboration have been greatlyenlarged now that the local health authority mustprovide health visitors, midwives, district nurses,and home helps, all of whom can directly aid thefamily doctor. How, in return, the practitioner is tocontribute more to preventive medicine is uncertain.Many local health authorities have tried invitingpractitioners to participate in the work of antenataland child-welfare clinics, and in school health work;but it is not always easy to reconcile the punctualattendance necessary for such work with the busyand irregular day of general practice. It seems thatthe general practitioner should be ideally placed for1. Reports of the Department of Health for Scotland and the

Scottish Health Services Council, 1950. H.M. StationeryOffice, 1951.

2. What Local Authorities can do to promote Health and PreventDisease. H.M. Stationery Office, 1951.

Page 2: Tasks for the M.O.H

88

the practice of preventive medicine and health educa-tion whether he collaborates in clinic work or not :"his intimate knowledge of the living conditionsof his patients and of their medical histories and

personal worries gives him unique opportunities forthe dissemination of information and practical adviceon these subjects." 3 Possibly we should even aim atmaking him the main exponent of preventive medicine.But there is some danger in confusing what oughtto be with what is. The practice of preventivemedicine and health education calls for an unhurried

approach which is at present too seldom possiblein general practice. Moreover, there is a real differ-ence between a clinical approach and a preventiveapproach. When the two are combined the resultis medicine at its best ; but most general practitionersare not in a position to give such a service, and bothmedical training and the conditions of practice willhave to be reoriented if such a happy position is tobe achieved.

3. Birmingham Executive Council : memorandum prepared forthe Executive Councils’ Association. Dec. 18, 1951.

Annotations

THE SCHOOL DENTAL NURSESTHE British Dental Journal for Jan. 1 contains a

long article, by a correspondent, analysing the NewZealand School Dental Nurses Scheme. With the aidof statistics, graphs, and selective quotations fromvarious recent reports on the scheme, this correspondentsucceeds in proving disadvantages in its operationwhich are not in fact denied bv advocates of the use ofdental ancillaries here. The case for -the legalisationof dental nurses is not destroyed by the " wastage

"

in the New Zealand scheme, caused by nurses retiringfrom the service, to marry or for other reasons, oftenonly a few years after completing their training : indeedwe cannot even be sure that there would be similar

wastage if a similar scheme were established in this

country. The reasons which persuade a woman toremain at work after marriage are functions of the

general economic situation, and in a time of inflationand continually rising cost of living the woman who hasundergone extensive training usually has strong incentivesto continue to employ her acquired skill, in order tocontribute to the family income. We may fairly guessthat in this countrv a dental nurse trained under thescheme proposed in the Dentists Bill would remain

long enough in the service to justify the expense of hertraining, even if this is not always so in New Zealand.This argument based on economic " wastage " wouldapply at least as strongly to women dental surgeons,whose training is more expensive ; yet we seldomhear the suggestion that the numbers of women admittedto the dental schools, which increases year by year,should for this reason be reduced. Actually the schoolservice is coming to rely more and more on womendentists, the staffs of some local authorities being almostentirely feminine. Many women dentists take full-time appointments in the school until they marry,after which they continue on a part-time basis ; andwithout their services the condition of the school servicewould indeed be parlous.

If it were possible to increase the numbers of dentistsqualifying from the schools, and then to persuade enoughof them to enter the school service, the problem ofchildren’s dentistry would be solved and we should nothave to consider whether it is or is not desirable to traindental ancillaries. But it is probably impossible toincrease the number of qualified dentists to this extentwithout disastrously lowering standards in the selectionand training of students. The tutor at a dental school

in this country lately found that, of a score of studentsadmitted for a degree course,, only two graduated with,out failing in at least one examination, and that the otherstudents between them took the equivalent of 32 academicyears more than they should have done, to complete thecourse. Almost certainly, if many more students areto be drawn into the schools, examination standardswill have to be lowered to allow the less talented to

pass. To us it seems that the real threat to thestatus of the dental profession, and of the service itrenders the community, lies in the lowering of standards.of admission to its ranks rather than in the employmentof ancillary workers, under professional supervision,as the Dentists Bill proposes.

Elsewhere in the same issue, the British Dental Journalreports the Minister of Education as saying that 3000dentists are required in the school service to bring itup to establishment. This establishment would almostcertainly be unable to provide a comprehensive service,and a minimum of 5000 might be a more realisticestimate. The conservative figure of 3000, however,is roughly four times the present strength of the service.Moreover we must suppose that the total strength of theprofession would also have to be increased-perhapseven quadrupled-before 3000 school dentists could berecruited ; for there is no reason to suppose that a

higher proportion would be attracted to the exactingwork of children’s dentistry than has been attractedin the past. In this country there is nt) more thanone dentist to 4400 of the population, whereas in NewZealand the proportion is one to 2890, and in the UnitedStates one to 1727 ; which suggests that the professioncould be increased to almost four times its present sizeand still be almost wholly absorbed in treating theadult population.One of the strongest arguments in favour of dental

nurses is that they are recruited exclusively for theschool service and receive a restricted training as

specialists in routine children’s dentistry. They haveno professional standing and cannot therefore " dilute

"

the profession or threaten its status. Provided the

degree of professional supervision of their work is

adequate, the public need have no fear that school-children will get an inferior service at the hands of thedental nurse. No investigator of the New Zealandservice has suggested that the quality of the treatmentgiven by the dental nurses is such that the scheme shouldbe abandoned.The central weakness of the British Dental Journal

article is its author’s assumption that we have a choice,now or in the forseeable future, between a children’sservice recruited entirely from qualified dentists and onemainly staffed by school dental nurses, of which the formermethod would in the long run be more economical.No such choice exists. We have to choose between the

present lamentable state of affairs and an experimentbased on the experience of the New Zealand scheme,which has, after all, been in operation for thirty years,apparently to the satisfaction of the dental professionas well as the general public.

1. Weibull, C. Nature, Lond. 1951, 167, 511.2. Pijper, A. Ibid, p. 749.

SEPTEM CONTRA PIJPER

THE medieval scholars are said to have employed thesummer in travel and reserved their disputations forthe darker days. Perhaps it is because winter is uponus that the argument on the nature and purpose ofbacterial flagella has come to life again.AVeibull is the latest to take the part of those who

do not believe that flagella are mere passive appendages :with the help of X-ray diffraction analysis he hasdemonstrated that they cannot be mucoid or poly-saccharide in composition. In his reply, the redoubtablePijper accepts the challenge and takes the opportunity