Research and administration - a profitable partnership
I am greatly honoured by having been invited to give this lecture in memory of Stephen Paget, the founder of this Society, who did so much to enlighten the public on the developments of modem, scientific medicine and of its great and ever-increasing value to the community. The span of his life (1855-1926) covered one of the most fruitful periods of medical research and coincided with the growth of a system of central and local administration that made possible both the promotion of research and the application, for the benefit of the public, of the findings of research. It is of this partnership between research and administration that I wish to speak this afternoon, for if the two partners understand one another's problems and work together harmoniously great profit may result.
Unlike most of those who have given this Lecture in previous years I am no research worker. During most of my professional life I have been engaged in the rough and tumble of public health-work, usually trying to persuade people to do things they didn't want, or couldn't be bothered, to do, and a target to be shot at when things went wrong. It has, however, been a satisfying life. All through it I have been a confirmed optimist and looking back on the past few years I really think much of my optimism has been justified. You will appreciate that my main concern has been with preventive medicine, in the widest sense of the term, and much of my attention has, therefore, been directed to the struggle against communicable disease.
If research and its application are to flourish certain administrative arrangements have to be made. Research workers, like any other workers, must have enough money to meet their living expenses, they must have premises in which to work and equipment and materials sufficient for their needs. In addition, if the public are to benefit from the findings of research there must be some means of educating the public in the hope of securing their co-operation. It was not till well into the nineteenth century that anything like adequate arrangements began to be developed in this country and, if I may, I should like to make some brief reference to the past.
Nineteenth Century developments
The 19th century was marked by the gradual growth of a system of democratically elected House of Commons, local boards of guardians to manage the new poor law, reformed boroughs and boards of health, and finally by the creation of county and county borough councils and urban and rural district councils. Central and local health departments were established, and by the end of the century elementary education had become compulsory and free to all. By 1858 the medical profession had been given a constitution and a General Medical Council whose powers enabled it to "exercise gradual influence, though no direct coercion, for the raising of the standards of medical qualification, and for the improvement of medical study."
Some of the administrative reforms of the century were due largely to the fear engendered in the hearts of the people, and more particularly of their legislators, by the repeated invasions of this country by Asiatic cholera. Sir John Simon, the first chief medical officer in central government, referring to the passage through Parliament of an important measure of sanitary reform, wrote " Just then however happened to come a moment of popular piety towards the cause of sanitary reform; for Asiatic cholera had begun to be again severely epidemic in parts of London; and this ill-wind (to justify the proverb) blew very favourably to fill our sails; so the Bill was rapidly made into law."
It is hard to realise nowadays how appalling were the insanitary conditions under which large masses of the population lived during much of last century. The picture was painted vividly by Chadwick in his monumental "Survey into the Sanitary conditions of the Labouring Classes of Great Britain," 1842, and by Simon in the reports he submitted while Medical Officer of Health to the City ofLondonfrom 1848 to 1855. Describing some of his experiences Chadwick wrote— "The description given by Howard of the worst prisons he visited inEngland(which, he states, were the worst he had seen inEurope) were exceeded in every wynd in Edinburgh and Glasgow. More filth, more physical suffering and more disorder than Howard describes as affecting the prisoners, are to be found amongst the cellar population of the working people of Liverpool,ManchesterorLeeds, and in large parts of the Metropolis." Science owes much to the genius of 19th century workers but the benefits to the community resulting from their labours would have been less readily obtained had it not been for the courage, the energy and the vision of a notable group of social and sanitary reformers of the same period.
With the creation of a central government department of health in the middle of last century and, more especially, with the appointment of Simon as its Chief Medical Officer, things began to move. Arrangements regarding vaccination against smallpox were greatly improved, systematic investigation of the more prevalent diseases was undertaken, and better use on a national basis was made of vital statistics. Before long the Department was authorised to promote certain laboratory investigations—" investigations," as Simon put it, " of sorts not likely to be undertaken on sufficient scale by private persons, in the branches of science collateral to our province of duty; investigations not necessarily connected with our practical business of the moment, but tending to be of powerful indirect influence on our practical business as a whole; investigations which we knew could be of no rapid effect, but which we hoped would by degrees—even if only by the slow degrees of exact science—surely lead us to more precise and intimate knowledge of the causes and processes of important diseases, and would thus eventually augment more and more the vital resources of preventive medicine."
By 1870 Parliament had approved an annual grant of £2,000 in the Department's estimates under the heading of "Auxiliary Scientific Investigations." The vote was significant, as Simon said, "not merely in its relation to the immediate uses of the Medical Department, but as expressing a national contribution to the world-wide general interests of medical research." A grant, though a somewhat larger one, under a comparable heading has, to the best of my belief, been included in the Department's estimates ever since. In my day it was known as the "C.M.O.'s Special Investigation Fund "—and very useful it was at times.
The second half of the 19th century saw great advances in physiology and in bacteriology and there was considerable laboratory activity particularly in the universities. This led—mainly at the instigation of the medical profession be it remembered—to the passage of the Cruelty to Animals Act in 1876. Under this Act inspectors are appointed whose duties are: —
a) to inspect premises registered for experiments on animals under the Act ;
b) to advise on applications made to the Home Office for licences or certificates, and to study all publications of licensees in which the results of experiments are described; and
c) to advise licensees and research workers on various matters particularly on how proposed experiments might be modified so as to exclude any objectionable features without sacrifice of the essential object.
I believe the work done by these inspectors has been most valuable and their help much appreciated by laboratory workers.
By the end of last century bacteriologists had discovered the causal agents of most of the communicable diseases. The use of glycerinated calf lymph had taken the place of arm to arm inoculation against6smallpox. Diphtheria anti-toxin had been prepared and was made available to all patients in the local authorities' fever hospitals and to general practitioners through the agency of the local health departments. As you know, the result was that mortality from diphtheria fell to about one third of what it was in pre-anti-toxin days. Almroth Wright had produced a vaccine of killed typhoid bacilli as a prophylactic against typhoid fever, though full use was not made of it till the first world war. Indeed Wright's suggestion that active immunisation against typhoid fever should be used for the protection of our armies overseas was at first rejected by the War Office, and it took much persuasion to reverse the decision. It is of special interest to us that, in the early days of the 1914-18 war, Stephen Paget volunteered to give lectures to our service men on the value of protective inoculations against tetanus and typhoid fever, which were being imperilled by prejudice and violent agitation. He was successful in removing much of the misconception that was obstructing these measures.
The century ended, then, with a system of central and local government much as we know it to-day, and with most of the filth diseases defeated if not eradicated. No longer did cholera, plague, typhus and typhoid play havoc with the health and lives of the people of this country. Smallpox was capable of control and even tuberculosis had begun to decline.
The Twentieth Century.
Advances in scientific knowledge and the promotion of social legislation have been phenomenal during the past fifty years. May I refer first of all to the National Insurance Act, 1911. This Act, in one of its clauses, provided for the setting aside of one penny per insured person for research into tuberculosis and other diseases affecting the insured population, and a Medical Research Committee was appointed in 191H under the National Health Insurance Commission to administer the fund, which at that time amounted to about £55,000 a year. The first world war gave the committee and its distinguished Secretary, Sir Walter Fletcher, the opportunity, of which they took full advantage, of demonstrating the possibility of fostering medical research through the agency of a central government committee. When the war came to an end and a Bill to establish a Ministry of Health was promoted, an attempt to place the Medical Research Committee under the new ministry—to which the work of the Insurance Commission was transferred—was successfully resisted. Instead, the committee was reconstituted as the Medical Research Council in 1920, under the statutory authority of the New Committee of the Privy Council for Medical Research, and the funds for its work were thereafter provided direct by the Treasury in the form of a grant-in-aid approved yearly by Parliament. The Council is a nearly autonomous body, composed mainly of scientists, with the widest possible terms of reference and with its field of operations unrestricted by territorial limitations. Few people can have foreseen when the National Health Insurance Bill was having its passage through Parliament in 1911 that its simple provision for research would, before many years had elapsed, result in the development of a governmental organisation for the promotion of medical research—with a budget of over £1£ million—which by its wise methods of administration would earn the respect and admiration of research workers all over the world.
It is generally accepted nowadays that the cost of medical research like that of university education must in large measure be a charge on government funds, and this country is fortunate in having such funds distributed by the Medical Research Council on the one hand and by the University Grants Committee on the other. Both these bodies enjoy a degree of independence and a flexibility of administration denied ordinary government departments; nor are they likely, by reason of their constitution, to be subjected to undue political interference. The need for research is, however, so widely recognised that in recent legislation—and here I am thinking particularly of the National Health Service and the National Insurance (Industrial Injuries) Acts of 1946— clauses have been inserted giving the appropriate Ministers power to conduct, or assist by grants or otherwise any person to conduct, research into the causation, prevention, diagnosis or treatment of disease. Such powers are doubtless to be commended but unless wisely exercised may prove to be costly and unprofitable. The medical staffs of government departments do in fact conduct numbers of field investigations no less important in their own way than laboratory research, and it is frequently through them that research problems are brought to light. They are not, however, specially chosen for their ability either to plan or to supervise research. Indeed, the number of well trained, competent research workers is, and I am afraid always will be, too small to tackle the number of research problems awaiting solution and it would hardly aid the progress of research to have various government departments and other organisations competing for their services. It is to be hoped that Ministers will see to it that before their departments embark on any extensive programmes of research they will consult with the universities and the appropriate research councils who are, after all, in a much better position to advise on such matters and to find and train and encourage persons possessing those qualities of mind and technical competence that make for a successful research worker.
So far I have tried to give a short description of the kind of administrative system that has been developed in this country—a system that is necessary if suitable facilities are to be provided for the carrying out of research and if the findings of research are to be applied for the benefit of the community. It is important that those who do research should not be too isolated from those who endeavour to apply its findings, and that those who carry the burden of applying research findings should in various ways be associated with the research workers, so that the one side can appreciate the problems of the other. I regard the time I spent with my scientific colleagues at the London School of Hygiene and Tropical Medicine, and as a Member of the Medical Research Council, as the most educative period of my professional life, and I am glad it has now been made possible for the chief medical officers of the Ministry of Health and of the Department of Health for Scotland to attend as assessors the meetings of the Medical Research Council. A good instance of the sort of association I have in mind can be found in the Public Health Laboratory Service. This is a service covering nearly the whole ofEnglandandWaleswhich grew out of war-time needs and is administered by the Medical Research Council though its cost is a charge on the budget of the Ministry of Health. The Service co-operates with the Ministry of Health, with local medical officers of health, with general practitioners and with hospitals, and it has proved its value over and over again. The first information as to the occurrence of some infectious disease often comes from one of its laboratories; its carefully controlled field trials paved the way for the introduction on a national scale of immunisation against diphtheria; and it has recently completed a test of a whooping cough vaccine that may well result in the general use of a more reliable prophylactic against this cause of high mortality among infants. Reference laboratories have been established in which special techniques have been developed, and a considerable volume of research work is always on hand. It was due to the vision of the late Professor Topley that this service was brought into being and, as was the case with all he did, the foundations were well and truly laid.
Education of the Public.
However well designed may be the administrative machine and however good may be the intentions of those responsible for its working, little benefit to the public health will result if the public do' not willingly and intelligently co-operate in the application of the findings of research. This is an old story and, to show that it is so, may I quote some of the words used by Sir John Simon in paying a tribute to Chadwick, the greatest of the 19th century reformers, on his compulsory retirement from government service at the early age of 54? "Mr. Chadwickbore In those days the distinction which has been many a great reformer's crown of laurel, that he was among the best abused men of his time. With his rare abilities as an initiative investigator in matters of social pathology and with his absolute rectitude of intention towards the public in every line of conduct which he followed, he was an administrator whom the government of the day could not uphold against hostile interests " . . . " The faults which were imputed to him in his official relations—so far as they were Mr. Chadwick's faults—may be generalised as faults of over-eagerness: faults, no doubt, which his opponents could not have found conciliatory, and which also in other respects would have tended to defeat his main object " . . . "He perhaps did not sufficiently recognise that the case was one in which deliberate national consents had to be obtained, and in which therefore no real, no permanent, success could be won except in proportion as the people and their representative bodies should have made way in a necessarily gradual process of education. He could not advisedly have thought it -possible to snatch his verdict and to revolutionise national habits by surprise; but he probably hoped to achieve in a few years the results which not ten times his few years could see achieved; and when others on all sides were hanging back, his ardour seemed ready to undertake the work of all."
The means of educating the public in Chadwick's day were meagre to say the least of it. Now, however, with a national and a local press, the B.B.C. and the educational work undertaken by local health departments—to say nothing of the fact that general education is compulsory and free—we ought to be able to enlist the co-operation of the public if we have a good case to lay before them. There are two sorts of emergency that ensure public support for measures designed to safeguard health. One I have already mentioned—fear. It was fear that, during the 19th century, forced the government to take steps to combat the repeated outbreaks of cholera, and in our own time we nave experienced the readiness of the public to respond to measures taken in the face of, say, an occurrence of smallpox. The other sort of emergency is war. The revelations of the sufferings of our troops in the Crimean War gave that remarkable woman, Florence Nightingale, her opportunity. The South African War shocked this country in many ways, but particularly on account of the very high rejection rate of recruits due to physical defects that might have been prevented. This led to the introduction of a school medical service and measures for safeguarding the health of mothers and young children. The first world war made possible the full use of T.A.B. vaccination and of tetanus anti-toxin, and stimulated schemes for the free and confidential diagnosis and treatment of veneral disease and a great extension of our hitherto inadequate arrangements for the care of tuberculosis persons. The last war gave us immunisation against diphtheria on a national scale, mass miniature radiography as an aid to the early detection of pulmonary tuberculosis, and the rapid development of new forms of therapy and of new and potent insecticides. During the last war, too, health became news, both in the press and on the radio. Unfortunately, .now that the emergency, if not over, seems at least less urgently present, the public are less impressionable. The newspapers, though still helpful in spite of their restricted space, tend to give preference to news of a somewhat sensational character. Thus an unusual outbreak of alleged ergotism in France is news, but little or no publicity is given to the facts that in 1950 the number of deaths from diphtheria in England and Wales was only 49 (as compared with an average of over 2,500 just before the late war) and that in the same year the infant mortality rate fell to below 30 per 1,000 live births (one fifth of what it was in the beginning of the century).
Before a specific method of treatment or prophylaxis becomes available in the case of a communicable disease many difficulties have to be overcome. The causal organism must as a rule be identified and isolated, in vitro tests must be done often with vast numbers of preparations, toxicity tests in suitable laboratory animals must be performed with such of these preparations as show signs of promise, and then specific tests against the particular organism must be carried out in susceptible laboratory animals. The key to success is the finding of a suitable susceptible animal, and in the absence of such little progress is likely to be made. You will recall how rapidly the study of influenza developed once it was found possible to convey the infection to the ferret and how handicapped we are in research on, say, the common cold through having to use human subjects instead of experimental animals.
When a preparation has passed successfully through its laboratory tests it must next be submitted to carefully controlled trials on human beings. These trials present fewer administrative difficulties in the case of a preparation intended for treatment than in the case of a prophylactic. The Medical Research Council has been of great help in this connection through its Therapeutic Trials Committee and, where prevention is the aim, through the Public Health Laboratory Service. Many of the preparations submitted for trial have come from the pharmaceutical firms whose scientific staffs have contributed so largely to the therapeutic advances of recent years. Once these trials have been completed and satisfactory results have been obtained, the preparation is ready for release to the medical profession or for sale to the public. But before this happens the requirements of the Therapeutic Substances Act of 1925 may have to be complied with. The purpose of this Act is to regulate the manufacture, sale and importation of those therapeutic substances that have to be standardised by biological methods. Its administration lies with the Ministry of Health, but the large amount of laboratory work involved has been done by the Biological Standards Department of the National Institute for Medical Research, whose international reputation in this field stands so very high.
Considerable administrative difficulties may be encountered when a new preparation, whether curative or prophylactic, is placed on the market, though the difficulties are not the same in both cases. Each new therapeutic agent has its advocates, stimulated not infrequently by skilful advertisement, and the result is only too often a quite unreasonable demand for its use both by the public and by the medical profession. This demand has been embarrassing at times during recent years on account of the fact that certain of these new preparations have to be imported from hard currency countries, while others are " in short supply " and very costly. Conditions labelled "rheumatism" or "rheumatoid arthritis " are particularly susceptible to plausible advertisement. Thus, from a sample of prescriptions examined recently in the Ministry of Health, it was shown that the cost to the country of one preparation advertised as a valuable therapeutic agent, but subsequently proved to be quite useless, actually amounted to 2.4 per cent, of the cost of all prescriptions in the sample under review. It was estimated, too, that Chloromycetin, prescribed at the rate indicated in the sample, might well be costing the country nearly £800,000 a year—a considerable under-estimate, I venture to think.
Immunisation against Diphtheria
If measures are needed to restrain the indiscriminate' prescription of new and costly remedies, the exact opposite is usually the case when steps are taken to make available to the public some reliable prophylactic. It is in these circumstances, we must remember, that the well intentioned, if misguided, opponents of every form of inoculation are apt to indulge themselves to the full, fortunately with but little success nowadays. Let me give a short account of the careful procedure followed inBirminghambefore immunisation against diphtheria was generally adopted. In 1922 the Schick testing of the nurses at the fever hospital was begun, followed in 1923 by their active immunisation. In 1925 the domestic staff were included and in the same year the immunisation of children in three residential institutions where diphtheria had been prevalent was undertaken. In 1926 immunisation was offered to the relatives and neighbours of those children in the fever hospital who were suffering from diphtheria. This was intended to test the probable attitude of the public towards a general scheme of immunisation. The offer was accepted with enthusiasm. In the same year a weekly immunisation clinic was opened in the city's public health department. In 1927 the first immunisation of school children was done in a Roman Catholic school, during play hours and after school. The following year other schools began to be visited, with the result that 1,387 children were immunised. In 1929 the Board of Education gave their assent to the inoculation of children on school premises during school hours as part of school medical treatment, and special clinics were started in the child welfare centres.
And so, after seven years of patient effort, the scheme was launched. By the end of 1933 approximately 50,000 children had been immunised inBirmingham. Although the number was not very large compared with a school population of some 150,000, the increase in the volume of immunisation was accompanied by a fall in the incidence of diphtheria in the city, and accommodation in the fever hospital that would normally have been occupied by cases of diphtheria was made available for children suffering from other conditions for whom it had not previously been possible to provide beds. It was estimated that the cost of immunising 13,000 children in 1933 amounted to £1,567 and that, taking the average cost of treating a case of diphtheria in hospital as £25, the city saved a sum of £22,000 on account of the greatly reduced incidence of the disease.
To bring the story up to date, 376,483 persons had been immunised inBirminghamby the end of 1950 and in that year there was only one death from diphtheria in the city. There were no deaths from diphtheria in the same year inNewcastle, Sheffield, Leicester, Nottingham,Portsmouth, Southampton,BristolandCardiff—indeed in 109 out of the 126 Great Towns inEnglandandWales.
In spite of the good example set by Birmingham and in spite of the encouraging accounts of the results of immunisation, particularly in North America, a national effort to eradicate diphtheria had to await the outbreak of the second world war when the importance of maintaining a high standard of health and of saving hospital beds, coupled with the findings of the Emergency Public Health Laboratory Service in their trials of the British prophylactic A.P.T., finally convinced the government of the need for action. In 1940 diphtheria prophylactic was made a free issue to local authorities and in 1941 a vigorous campaign in favour of immunisation was opened in the press, on the radio and by the local authorities themselves. As a result, the incidence of, and mortality from, diphtheria fell steadily till in 1950, as I have already indicated, the total number of notifications in England and Wales was only 980 and the deaths 49. When it is recalled that the number of deaths in 1938 was nearly three times the number of notified cases in 1950, we have no reason to be ashamed of what has been accomplished in ten years. We may regret that for one reason or another the official stimulus was not applied at an earlier date. Diphtheria is now becoming so comparatively rare that it is often difficult to find suitable cases for demonstration to medical students, and the public are losing their dread of the disease to such an extent that they may no longer appreciate the need for protection against it. Every effort must be made to secure the protection of the largest possible proportion of the infants born in this country if we are not going to see the gains of the last few years slipping away. As immunisation against diphtheria has been made one of the functions of the family doctor under the National Health Service Act, it is greatly to be hoped that he will use his influence with the parents in his practice to convince them of the value to their children and to the community of this simple form of prophylaxis.
The use of B.C.G. vaccine, as a means of increasing immunity against tuberculosis, is another example of the detailed administrative steps that must be taken when such a preparation is made a government issue. Largely as a result of the claims made for this vaccine in the Scandinavian countries, it was decided in 1946 to arrange for its availability under certain conditions in this country. It was also decided to use a vaccine from a known and well tried source rather than to produce it ourselves, at any rate in the first instance. Arrangements were accordingly made to obtain the vaccine fromCopenhagen. As the vaccine is composed of living, though attenuated, tubercle bacilli it is advisable to use it within ten days of production. This means that it has to be imported by air, collected by despatch-rider .at the airport, stored over night and distributed rapidly throughout the country. Sterility tests have to be done inCopenhagenand, as a further check, are repeated in our own Central Public Health Laboratory immediately on arrival of the vaccine. The persons to be inoculated, who must have been proved to be negative to the Mantoux or other reliable tuberculin test, must be selected well in advance, for there is little margin of time. At present the use of the vaccine is limited to nurses, medical students and family contacts of open cases of tuberculosis, though the Medical Research Council are conducting at the same time a carefully con- trolled trial among children of school-leaving age. Accurate records of all persons inoculated are being kept and adequate arrangements for follow up have been made. All this is necessary if we are to discover whether the use of the vaccine on an extended scale is to be advocated in this country. It is maintained that conditions here are different from those in the Scandinavian countries, where the vaccine has been accepted with few reservations. Indeed in Copenhagen it is estimated that between 120,000 and 140,000 persons out of a population of rather less than a million have been vaccinated, and it is stated that no case of tuberculous meningitis, miliary tuberculosis or progressive pulmonary tuberculosis has been observed throughout the period 1935/50 among the children known to the central tuberculosis office as having been successfully vaccinated with B.C.G. Yet some of these children lived in homes to which one or more persons with open tuberculosis belonged. In practice, the number of hospital beds required for tuberculous children has been appreciably reduced. It is to be hoped that B.C.G. will be proved to be a useful additional weapon in our fight against tuberculosis in this country, though it must not be regarded as a substitute for those other measures whose value has stood the test of time.
Nowhere is the need for combined operations between research workers and administrators better illustrated than in the field of national nutrition. Administrative action up to the beginning of this century was confined mainly to dealing with the giving of short measure, the gross adulteration of food-stuffs and the seizure of unsound food, and to laying down some simple requirements regarding the clean handling of food, especially milk. It was known that milk was a not infrequent vehicle for the spread of typhoid fever, scarlet fever and other infective conditions and that helped to stimulate the passing, of some useful legislation. With the growth of a better understanding of the importance of nutrition as the basis of good health, more practical measures began to be taken. A small beginning was made with the provision of school meals for necessitous children, infant feeding was studied intensively in the rapidly extending system of infant welfare centres and later a "milk in schools " scheme was introduced. Army rations were planned on a more scientific basis, especially as a result of the experience gained in the 1914-18 war. Urgent demands began to be made by public health workers and others for the pasteurisation of bulk milk supplies, as it had been shown that a considerable proportion of such milk contained living tubercle bacilli. It was pointed out with some reason that human beings, especially children, deserved at least as good treatment as that given to attested cattle, i.e. herds certified free from tuberculosis. Under the Attested Scheme one of the requirements is as follows:—" No milk or dairy by-product shall be brought on to the premises of an attested herd for feeding to animals except direct from the premises of another attested herd unless such milk or dairy by product is pasteurised or sterilised by heat." It was not till a year or two ago that an Act was passed which enables the Minister of Food to specify areas in which only pasteurised, sterilised or tuberculin tested milk, and for a limited period accredited milk from a single herd, may be sold. I believe at least two such areas—LondonandPortsmouth— have been specified. During the late war, however, a real effort was made to give practical effect on a national scale to the scientific knowledge regarding human nutrition that hid been accumulating during the preceding quarter of a century or so. War conditions made necessary the preparation of a plan for national nutrition. So the requirements of the various sections of the population were defined in terms of nutrients and the amounts of different foods needed to supply these nutrients were estimated. Production and import programmes were planned accordingly. The Minister of Health was made responsible for advising the Government on nutritional policy and the Minister of Agriculture had to endeavour to produce food and the newly appointed Minister of Food to import and distribute food in accordance with such advice. Thus the newer knowledge of nutrition was applied for the first time, on a nation-wide scale, to the feeding of the people ofBritain.
Lord Woolton, as Minister of Food, lent a ready ear to his scientific advisers, and to show what was in his mind I cannot do better than quote some of his words spoken in 1942. " I think we shall be able to say when the war is over that, as a result of the application of scientific knowledge to food, we have enabled the next generation, which has to build a new age, and which indeed has a formidable task before it, to. approach the work with healthy bodies. I believe we shall go through this war with no malnutrition amongst the children of the nation. That is one of the things for which we are working and praying, and I hope we shall succeed." How well we did succeed is known to all. Certain priority classes were recognised. Under the Welfare Foods Service the expectant mother was entitled to seven pints of milk a week at less than one third of the market price or free if she could not afford to pay, free cod liver oil or vitamin A and D tablets, and for a small payment a supply of concentrated orange juice. Additional eggs and meat were also allowed her. Special provision was made for the mother when she was nursing and for the infant till it reached the age of five years. When the child went to school it had the benefit of the School Milk and Meals Service. By the end of the war mothers and children were getting some 2H0 million gallons of free or cheap milk a year, about 40 per cent, of the nation's supply, and just over 50 per cent, of children attending State-aided schools were enjoying a well balanced mid-day meal of a calorie value of some 1,000 for the older and 750 for the younger children. All this called for a vast amount of administration, but it was worth it, for during the war and since, infant mortality, neonatal mortality, the still-birth rate and even maternal mortality itself have continued to fall year by year to record new levels. Of course all of the fall has not been due to improved nutrition; other forms of care have not been neglected and full employment has helped; but I have no doubt whatever that nutrition has played an important part. And as for the children themselves, their healthy, sturdy appearance has been the wonder and admiration of all visitors to this country.
One of the unfortunate accompaniments of the development of scientific techniques has been the growth of the sophistication of food. Various food stuffs are " improved " or " purified," something may be extracted or something else added, till it is hard to say at times what we are eating. Nutritionists have long wondered why bread, which still forms the staple food of a large proportion of the population, should have been made from flour from which some 30 per cent, of the original wheat had been removed, including a large portion of the most nutritive part of the grain. But the war changed that too, perhaps more from the need to save shipping space by using a flour of a higher rate of extraction than from any general desire to provide a more nourishing loaf. Flour, which at one period of the war contained as much as 85 per cent, of the original wheat, stands to-day at about 80 per cent, extraction. Milling methods have improved markedly and we now have an attractive loaf of much greater nutritive, value than we had before the war
War-time conditions made necessary a vast increase in communal feeding and much of it still persists. One result of this is that any infection of the food served in a canteen may possibly give rise to a large number of cases of, so called, food poisoning—so large as to attract public attention and receive notice in the press. Many outbreaks of this nature have occurred and the Public Health Laboratory Service has made a number of valuable contributions to our knowledge of the subject. Modern laboratory techniques make it possible at times to trace the origin of such an outbreak to an infected person engaged in handling food, often an apparently healthy carrier of one of the causal organisms of food poisoning. The only way of preventing such mishaps is by the exercise of scrupulous cleanliness by every person engaged in preparing or serving food. This is no easy object to attain as many of our food premises are poorly equipped with washing facilities— especially in juxtaposition to the toilets. 'The Minister of Food appointed a committee a year or two ago to study the question of hygiene in catering establishments and the committee reported recently. It is to be hoped that its recommendations will result in adequate administrative action. Earlier efforts to educate the public in this matter were not helped at the time by the refusal of certain newspapers, from some perverted sense of modesty, to include in any official publicity material they were asked lo print the simple warning "Wash your hands after using the W.C." Some recent applications of Research
But I fear I am wearying you with too many personal reminiscences. Let me in conclusion refer briefly to a few of the other ways in which the findings of research workers have proved to be of great practical value.
In diagnosis, the use of phage-typing and Moore's swabs make it possible to track down a typhoid carrier from a sewer outlet right through the drainage system to the very pipe taking the discharge from the carrier's own house. The diagnosis of smallpox can now be confirmed by laboratory tests, and indeed in a recent outbreak of smallpox it was the laboratory that in fact made the diagnosis in the first instance.
With the coming of the sulpha drugs, the anti-biotics, the anti-malaria drugs, and D.D.T. and other insecticides, the whole picture of the prevention and treatment of communicable disease has been altered. The new drugs, besides having a clinical value in the treatment of established infection, are by their bactericidal and bacteriostatic activity helping to eliminate the reservoirs of infection. This was shown to be true in the case of cerebrospinal meningitis and of bacillary dysentry during the late war. It may also be true as regards syphilis and gonorrhea, for both these conditions are highly susceptible to treatment with penicillin. It is stated that acute gonorrhea can usually be cured by a sinsle injection of 150.000 units of procaine penicillin in oil with aluminium monostearate, and that a tablet of 250,000 units of penicillin by mouth will even prevent the disease. A better understanding of the use of mepacrine and other anti-malarial drugs, whether curative or suppressive, made possible the success of the campaign in the S.W. Pacific, as was related by Sir Neil Hamilton Fairley in his Stephen Paget Memorial Lecture in 1946. D.D.T. and other new insecticides are lethal for the louse and the mosquito and so have removed much of the dread of typhus fever and have revolutionised life in malarious countries.Cyprushas been rendered practically free from malaria, and inGreece, which was the most heavily infected country inEurope, malaria has ceased to constitute a serious public health problem. Incidentally, side by side with the fall in malaria, infant mortality inGreecehas declined, sand-fly fever has well-nigh disappeared and farm production has increased.
Tetanus toxoid and yellow fever vaccine are now established prophylactics. Typhus and typhoid fevers are amenable to treatment with Chloromycetin; streptomycin and P.A.S. are proving helpful in pulmonary tuberculosis; lobar pneumonia has lost much of its terrors, and sepsis, especially puerperal sepsis, has yielded to the new forms of therapy. And now cortisone has opened up enormous new vistas.
Of course, all is not plain sailing. Nature will see to that. Difficulties such as drug resistance and unpleasant side effects may be encountered, but in the light of all that has happened in the past dozen years or so we can surely be hopeful as to the future. The last war strengthened the partnership between research and administration. What we need now is a peaceful world in which we can consolidate our gains and apply our ever increasing scientific knowledge for the benefit of mankind.
At the close.
Lord Hailey said how much he, although a layman and imperfectly acquainted with many of these matters, had enjoyed and learned from this lecture. He called upon Dr. Andrew Topping to propose a vote of thanks.
Dr. Andrew Topping: It is a great pleasure and privilege to propose this vote of thanks because I am a very old friend and colleague of Sir Wilson. It was also a surprise that I should be asked because, somehow or other, I had avoided becoming a member of this Society. I remember the first time I heard Sir Wilson speak. It is 44 years ago, and he was then finishing up as president of the Students Representative Council atAberdeenUniversity. He has said that he has not done much research, but I remember that in those days I was a great admirer of his researches. He spent a great deal of his time in outside activities, and I particularly admired the way in which he investigated all possible methods of getting through his professional examinations, hard routine work, of course, being excluded!
It is amazing to have such a complete coverage of all the main public health activities of the past fifty years and longer in the compass of less than an hour. He has shown that research and administration must go hand in hand. He had not time to refer to the most recent Campaign—more recent than the campaign for diphtheria immunization —namely, that against whooping-cough, which is just in the process of being concluded. It has meant an exceedingly difficult administrative and research project, and the results which have been made public in the medical papers give us every reason for hope that whooping-cough has lost its powers as diphtheria has done. I propose that this meeting accord to Sir Wilson Jameson a hearty vote of thanks for this most stimulating and erudite address.
The vote of thanks was accorded by acclamation.
ANNUAL GENERAL MEETING
The Annual General Meeting of the Society followed immediately, Lord Hailey remaining in the chair.
Hon. Treasurer's Report
Mr. Reeve Wallace (Hon. Treasurer) said that he need spend very little time in explaining the Accounts because the Accounts were already before the members with the Annual Report of the Committee, and he hoped—although perhaps he could hardly expect—that members had read them and would be prepared to criticise. The position of the Society as a whole was very satisfactory. The surplus of income over expenditure was £o8, comparing with £37 last vear. The subscriptions amounted to £700 as compared with £543. On the other hand, as with every other body, expenses had gone up considerably, not perhaps so very much comparing 1949 with 1950, but in the current year there had been a large increase. He drew attention particularly to the rise in printing costs and stationery. In the year under review this item amounted to £276 as against £117 the previous year, but so far as could be judged, during the current year this expenditure would go up to £350. He asked members to try to get new members; so far there had been 53 new members enrolled up to the time of this report.
The Hon. Treasurer's report was adopted unanimously.
The President said that the nominations for officers and other members of the Committee were on a sheet which had been distributed. The names would, if there was no objection, be taken en bloc. One change would be noted—that Sir Wilson Jameson was nominated to the chairmanship in succession to Dr. A. V. Hill. On behalf of the Committee and the Society in general, he expressed their deep sense of obli-