A paper by Dr Cook, read at a meeting of the Federation of Country Local Associations, New South Wales Branch, British Medical Association, Canberra, April 20, 1954; Reprinted from The Medical Journal of Australia, November 13, 1954, page 769.
The purpose of my talk today is twofold: first, to invite your attention to the importance, indeed the indispensability, of the general practitioner in any organized system of preventive medicine; and secondly, to prompt you to initiate a movement within the profession to have the family doctor integrated into your own State’s public health organization. I wish to impress upon you that I shall speak, not as an officer of the Commonwealth Department of Health expressing the views of the Department whether avowed or supposed, but as a fellow member of the British Medication Association, and one of a family which all the bread-winners of three generations in Australia have been medical practitioners.
Let me first state the functions of a public health department as I see them. These I believe to be the following: (a) to study the incidence of disease and the cause of morbidity and mortality in the community; (b) to identify the factors which are preventable and to devote itself to removing them; (c) to initiate and foster research into improved methods of diagnosis and into methods of treatment calculated to shorten the period of illness or avert a fatal outcome, to extend the knowledge of these, and to provide facilities for their universal application.
Public health departments as they exist today are successors to the English organizations of a century ago, and in structure, function and technique have not materially changed since first designed. The sudden population movements of the industrial revolution produced in Britain conditions of extreme overcrowding and squalor. These in turn were associated with an appalling incident of and mortality from infectious disease. The relation of these phenomena as cause and effect began first to be realized about the middle of last century, when Chadwick (1842) reported upon the sanitary condition of the labouring population of Great Britain. He ascribed epidemics to filth, overcrowding and impure domestic water, and advocated for their control organized drainage and scavenging, improved water supplies, and better ventilation and lighting in dwellings. His “sanitary idea” hypothecated that all epidemic disease was produced and fostered by the effluvia and miasmata associated with bad environmental sanitation. Completely unaware of the infectious nature of communicable disease and the part played by environment in assisting the passage of infection, he eventually succeeded in stirring a national effort to improve the sanitation of towns as a means of preventing disease. Having regard to his premises, it was natural, indeed inevitable, that when his recommendations were implemented the functions and duties of public health administration were vested in the local authority, and that the enabling legislation was restricted in its scope to activities within the capacity of that body to perform. With the local authority powers under the Health Act have remained ever since, subject in Australia only here and there to advice from a trained medical officer of health. In this country subsequent amendments to the original legislation under which the local health authority operates have elaborated the old rather than introduced new functions; indeed, what expectation could there be that such a body would either initiate a demand for wider powers in preventive medicine or attain the technical competence to warrant being entrusted with them?
The improvement in environmental sanitation achieved by these bodies has resulted in the elimination of a great mass of disease, which the old conditions directly fostered; but the disappearance of these has revealed a substratum of preventable disease which is not susceptible of further reduction by the measures available to a lay operative staff. It might be said that we have in great measure corrected the epidemiological factors introduced by our habitual concentration in fixed communities, but have still to eliminate those which would confront an uncivilized nomadic people.
Nevertheless, the organization of the public health departments in most Australian states has not been modified to meet the new situation.
Let us consider briefly a few of the ingredients of that persisting hard core of disease which cannot be expected to yield to Chadwick’s methods, however zealously and efficiently applied.
Acute Rheumatism
Precise information regarding the incidence of acute rheumatism in Australia is unobtainable. That the disease is only too common, however, is revealed by the fact that amongst the infectious diseases rheumatic heart disease is the most consistently high killer in the Commonwealth except tuberculosis. Bryan Dowd says of New South Wales that rheumatic fever is the commonest cause of death in the ten to fourteen years age group, and that one-fifth of the medical beds in the Royal Alexandra Hospital for Children are permanently occupied by patients suffering from rheumatic heart disease. Indeed, if allowance is made for medical beds devoted permanently to the care of infants requiring the correction of feeding errors, the proportion allocated to rheumatism becomes two-sevenths.
Some idea of the incidence of rheumatism in Australia may be gleaned from the experience of the United States of America, where it is estimated that 2% of school children suffer from rheumatic conditions of the heart, and that rheumatic fever is responsible for 80% to 90% of all heart disease of persons aged below twenty years. Three hundred thousand persons have been rendered unemployable by rheumatism, and 147,000 are permanent invalids.
Attempts to assess the incidence of rheumatism in Australia have not so far been successful. Only recently have certain States been induced to make the acute condition notifiable. Medical practitioners have failed to cooperate in notification for a variety of reasons, and the departments, always reluctant to increase the list of notifiable diseases, have contemplated discontinuance of notification rather than recourse to measures designed to improve its efficiency. Meantime, the organization for public health administration being what it is, medical practitioners who have notified rheumatic fever have been dumbfounded and embarrassed by the agents of local authorities visiting the homes of the patients and insisting upon house disinfection.
Salmonella Infections
Through the year in all the Australian States, epidemics of food poisoning are numerous, recurrent and extensive. Although Salmonella infections are now notifiable in three States, notification, depending as it does upon bacteriological identification of the causal organism, represents but an infinitesimal fraction of the amount of disease actually occurring. Some idea of the prevalence of these infections may be derived from the number of prescriptions under the Pharmaceutical Benefits Act for drugs used exclusively for the treatment of diarrhoea and dysentery – sulphaguanidine, phthalylsulphathiazole and succinylsulphathiazole. In 1953 these totalled 168,000. As a measure of the incidence of Salmonella infection, this figure must be recognized as excluding sufferers treated as either in-patients or out-patients by hospitals, and patients treated with antibiotics or by more traditional methods or not treated at all.
These infections being due to the unclean preparation of food in the hands of the individual or to the use of food from infected animals, control depends upon identifying the particular organism involved and tracing the source of contamination. For this task the local authority is unequipped, and only the general practitioner in contact with the patient can provide the basic information and material to form the starting point for investigation.
As an indication of the importance attaching to a thorough study of epidemics caused by Salmonellae, apart from the objective of controlling them themselves, let me recall to you a recent experience in the eastern States. For several years typhoid fever has occurred only sporadically and is now but rarely seen by the general practitioner. Throughout New South Wales cases have averaged only about one per month in a normal year. Towards the end of June and early in July, 1953, an unusual prevalence of typhoid was noticed in New South Wales and Victoria. By the end of July notification in all States totalled 12 for one week. During the next seven weeks there were 101 cases, and for the six months ending December 31, 1953, the total was 175. Infection was traced to contaminated imported food; but the point of crucial importance that the clue permitting the source to be identified was the association of S. typhi with a Salmonella new to Australian pathology – S. senftenberg. It was subsequently ascertained by bacteriological investigation that S. senftenberg had been a contaminating organism in this product for many months previously, doubtless in that time contributing significantly to the incidence of food poisoning. Had the notification and identification of Salmonella infections been efficient, the contaminated character of the imported would have been recognized months before it was, and effectual action then to control the sale of the product would have prevented the outbreak of typhoid without a case occurring.
Influenza
The possibility of a virulent pandemic of influenza of the character of that of 1919 must always be faced, and it is the responsibility of health departments to do everything possible to avert this. Control by vaccine can be quite efficient, but it depends upon isolation of the specific strain of virus involved. At least five weeks under optimal conditions is required to complete a batch of influenza vaccine. It is obvious, therefore, that if an epidemic or pandemic is to be averted by mass vaccination, public health practice must permit the early recognition and prompt typing of the virus involved, and a full and free interchange of epidemiological information between States and countries.
An organization capable of giving this service can be based only upon full and trained cooperation at the general practitioner level, since it involves not only notification of suspected disease, but the prompt collection and transmission of virological material.
Virus Pneumonia
Primary atypical pneumonia or virus pneumonia was certified as the cause of 71 deaths in 1952. The number of fatalities may have been considerably higher, for of 2,863 deaths attributed to pneumonia the type was unspecified in 609, and 1,505 were simply described as broncho-pneumonia.
Contributing to the incidence of this condition are influenza, psittacosis and “Q” fever. Psittacosis is probably much more prevalent in Australia than has been suspected. Although it is notifiable, total notifications are not more than one-half the proven cases. Miles is of the opinion that the high mortality reported in Australia is probably due to failure to recognize or identify mild cases. Recently an epidemic of aseptic meningitis at Port Augusta, in the course of which there were some 30 cases, was found to be caused by a virus similar to that causing psittacosis. Miles reports that 3% to 4% of inland aborigines examined in the Northern Territory had antibodies to psittacosis in their serum. It is important that the true incidence of psittacosis be ascertained; but obviously this can be effected only with full cooperation of the medical attendants in charge of patients. It is important because psittacosis contributes in an unknown degree to the incidence of virus pneumonia, and because the broad spectrum antibodies used in the treatment of virus pneumonia increase the carrier rate of psittacosis infections. Miles is of the opinion that a quite small variation in the character of the virus would give psittacosis a much greater public health significance than it is accorded today, and an efficient public health department should be alert to anticipate and forestall such a contingency.
The incidence of “Q” fever in Australia has not been carefully ascertained. This infection also contributes to the morbidity and mortality associated with virus pneumonia. Determination of its incidence, relying as it does upon serological examination of the blood of patients and convalescents, is essentially a matter for initiation by the general practitioner.
Cancer and Heart Disease
You may hold that the general practitioner can contribute little or nothing to the solution of the problems presented by cancer and heart disease, those two major killers. I suggest, however that for statistical studies of early signs or for late review none can better provide the fundamental information necessary to complete study. None, moreover, can better assess the need for local aids to early diagnosis or supply information upon requirements for early and effectual treatment.
Infant Mortality
For every 12 surviving live births in Australia one infant life is lost by stillbirth, prematurity or birth trauma before the end of the first week of extra-uterine life. Action to identify and correct the factors principally contributing to foetal death, prematurity and neonatal mortality in this country must await the laborious collection of a mass of statistical data. The National Health and Medical Research Council has recommended adoption throughout Australia of a method of collecting this information based upon a medical certificate of birth and a special certification of foetal death. Although medical practitioners chiefly concerned – the Royal College of Obstetricians and Gynaecologists – have in all States endorsed and strongly supported the recommendation, progress has been halted at the administrative level because statisticians, registrars-general and health departments, who must together provide the administrative machinery for collecting and collating the information have hesitated to ask for the necessary cooperation of the individual practitioner. I am persuaded that the profession as a body would regard collection and collation of this information as a most important forward step, and that it would welcome the opportunity to cooperate, but because there are no liaison between department and practitioner, no means of explaining the method and purpose to the profession, and no opportunity to ascertain the practitioner’s point of view, we have reached a condition of stalemate. In this as in all else it is quite clear that there is a compelling need for some vocal and executive organization of the general practitioner in public health.
If you recall for a moment the functions of a modern health department as set out earlier in this talk and relate them to the control of the conditions since discussed. I m sure you will be impressed by two facts: (i) There could be no prospect of reducing the incidence of the afflictions by any means available to a lay authority or by the most zealous application of conventional local health authority methods. (ii) To have any prospect of ascertaining the incidence of or reducing the morbidity and mortality from these conditions, a department of public health would require some effectual power of direction over the general practitioner to secure his active and complete cooperation in the diagnosis and reporting of disease and in the application of prophylactic and therapeutic measures designed for its control.
In addition to those incidental to its interest in specific diseases, a health authority in pursuit of the objectives cited may be expected to make other calls upon the cooperation of the general practitioner.
Health Education
Effectual and complete control of preventable disease is practicable only in a community so enlightened and disciplined that the individual without conscious effort himself on all occasions applies the controlling measures and habitually conforms to the sanitary prohibitions dictated by prophylaxis.
A modern and well-concerted plan to prevent disease must include the education of the mass of the people in prophylactic measures which are the responsibility of the individual, and the inculcation of a self-imposed discipline which will assure their universal and constant application.
Of all persons concerned with the study, prevention and control of disease, who is better situated to undertake this task than the family doctor, who sees the individual in his own environment, is trained to perceive the dangers of habits and practices contributing to disease, and can with assurance warn and advise upon their correction?
Immunization
The public health department may aspire not only to the universal artificial immunization of the child population against certain diseases, but to the preservation of accurate, accessible and permanent records of inoculations performed. These could be readily obtained in organized public prophylactic clinics; but haphazard and unrecorded immunizations in private practice may prove an intolerable embarrassment.
Child Health Services
Most health departments have come to realize that there are many inadequacies and imperfections in the medical and health services provided for the infant and for the pre-school and school child, and that these can be remedied only by invoking the more active cooperation of the family doctor in the work of the service. Calls upon the general practitioner for these services may be more exacting in one State or locality than in another; but any departmental response to the current impulse towards improving these services must involve the general practitioner either in close liaison or in conflict with the health authority.
Use of Antibiotics
The widespread use of antibiotics presents several problems. The broad spectrum antibiotics offer the busy practitioner an opportunity to effect the prompt cure of many infectious disease without delay, trouble and expense of making a precise diagnosis. The health authority cannot afford to overlook the following serious consequences of this practice: (a) The practitioner’s aptitude for clinical discernment and appreciation is apt to be impaired by disuse. (b) Inappropriate use or dosage may promote the development of resistant strains amongst organisms at present susceptible. (c) Patients may be rendered sensitive to the antibiotic at a time when its use is not required, and thereby denied it when its exhibition may decide between life and death. (d) The patient may be converted to a healthy carrier of infection undiagnosed and unsuspected, or he may, be a disturbance of a biological equilibrium in the bacteriological flora carried, be left vulnerable to another and possibly more serious infection. (e) A costly therapeutic agent purchased by the Treasury may be used unnecessarily instead of a cheap and equally or more efficient alternative.
Psychosomatic Medicine
Amongst the morbid conditions contributing heavily to the sum of human misery and the aggregate cost of medical treatment, hypertension, peptic ulcer, rheumatoid arthritis and others are now claimed to have an emotional background, recognition and palliation of which may promise real relief. Every actively functioning and progressive department of health will be impatient to take up the challenge of this doctrine, to assess its verities and to exploit its realities in the prevention of suffering and the reduction of therapeutic costs. For these purposes, what agency could it use more conveniently situated or more suitable trained than the family doctor – indeed, what other agency exists?
Discussion
One could multiply these instances almost to the exhaustion of all clinical conditions known to medicine; but I hope I have cited sufficient to prompt in you a recognition that the time has arrive when new measures for the study of disease and its prevention are an inescapable necessity. I hope, too, that I have convinced you that the proper functions of a health department involve; under modern conditions, a definite integration of the practising profession into any system of organized preventive medicine, and a strict discipline of its individuals either voluntarily self-assumed or statutorily imposed.
You may be prepared to acknowledge the principle that the general practitioner must play an important, indeed a decisive, part in any improved organization for the prevention of disease; but you may feel that the calls upon your time in practice preclude your undertaking it. You will argue, perhaps, that the responsibility of resolving this deadlock must rest elsewhere, and that the initiative lies not with you but with the department set up and maintained by government to devise and apply measures for improving the public health.
Let me remind those of you who share this last conviction that most of the health departments in Australia have been developed in the Chadwick tradition. Their structure and the legal codes which they administer are outmoded. The limited scope of the State Health Acts and their dependence upon local application by lay administrative bodies have together operated to frustrate the expansion of health departments into new fields.
Governments have been understandably reluctant to impose new tasks involving medical or technical knowledge upon local health authorities, and problems created by the inertia or incapacity of these to cope with new specialist functions have usually been met by the creation of new segregated departments operating under special laws. Hospital management, for example, has been divorced from health administration in some States, and from the control of poisons and therapeutic substances in most. Health departments in this way have been deprived of sources of information and denied opportunities for intervention which are fundamentally essential to the proper discharge of their own functions.
Adoption of a modern and improved pattern of health administration will involve in some States reorganization of the health department, not only to permit its assumption of functions and duties proper to its purpose which are at present excluded from its scope, but also to restore it to the administrative status from which, over the years, it has been deposed.
The magnitude of this task with its calculated assault upon vested pubic service interests makes it one unlikely to be undertaken by any State Government on the initiative of an unvalued and submerged health department or in the absence of an insistent public demand.
That public agitation for a comprehensive revision of health administration must develop I shall now endeavour to show. Let me, however, preface my remarks by stating my conviction that unless this agitation is deliberately canalized to these ends, it will not be directed either toward State Governments or toward improved preventive medicine.
In this country the incidence of taxation for social services is not light, and it extends to the great mass of wage-earners. The financial stimulus which first demanded government assistance in lightening the burden of medical expenses incurred by the individual must, as he gradually becomes aware of his continuing, if less manifest, obligation, be redirected towards a demand for reduction in costs.
Under a national health service scheme, unless special corrective action is promptly taken, costs must be expected to rise progressively for many reasons. To quote but two, one may mention the impulse of the individual to obtain each year full value for his annual tax contributions, impelling him to seek attention for trifling conditions which otherwise he would ignore, and the tendency of the medical profession to have recourse to costly methods of diagnosis and treatment formerly avoided out of consideration for the financial condition of the patient.
Costs already high are considerably inflated by several of the conditions we have considered as possibly being preventable. During 1953, for example, the cost of prescriptions for drugs used exclusively for the treatment of enteritis outside hospital was over £100,000 – just one-sixth of the total Commonwealth expenditure on pharmaceutical benefits for the year 1952-1953. This figure, be it clearly understood, takes no account of the expense incurred by the Commonwealth in the treatment of diarrhoeal disease by antibiotics or by sulphonamides other than those mentioned, nor does it include the cost of treatment of in-patients or out-patients by hospitals. The cost of rheumatism to Sydney’s Royal Alexandra Hospital for Children alone approximates £40,000 annually. The aggregate disbursement by the community for its treatment in other hospitals and in private practice, or involved in the payment of pensions, insurance claims and the like, is incalculable.
It is an anomaly of our federal system that the authority collecting the social services contribution and providing funds for the treatment of disease under the National Health Service Act – the Commonwealth – has to hand no direct means of developing a system of preventive medicine with the object of reducing the costs entailed in the treatment of preventable disease. By contrast, the authority charged with the prevention of disease – the State health department – incurs no comparable financial disadvantage from its failures nor commensurate advantage from its successes.
Increasing agitation to reduce the social services contribution without impairing benefits is likely therefore to be an embarrassment only to the Federal authority and to leave the State unperturbed. Any response to a public demand for economy must be expected first in the field of Commonwealth administration. Faced with a necessity for economizing, the Commonwealth is likely to turn first to revision of the fees paid for therapeutic services – a probability which gives you individually and collectively a financial interest in the initiation and furtherance of plans to improve and extend measures for the reduction of morbidity throughout Australia.
As an alternative, or as a supplement to revision of the feeds paid for service, the Commonwealth can have recourse to some device whereby acceptance of a therapeutic fee by a medical practitioner will involve him in an obligation to perform one or more routine services required as part of a concerted national research or control project. Such a device might well, unless carefully planned and policed, sooner or later deteriorate into a form of regimentation repugnant to you.
Conclusion
In closing, let me suggest that you have a national obligation, a financial incentive and a professional interest in the reformation and reactivation of public health administration in Australia, in order that there may be evolved a system of preventive medicine better designed to cope with the new problems revealed by present knowledge and more readily able to grasp the opportunities offered by modern research. Who, better than yourselves, can provide the central health authority, whether State or Commonwealth, with the active inspiration derived from daily contact with the personal problems of the patient and with the realities of medical practice?
Let me express the hope that you will promptly set yourselves to planning and to discussing with your State health department the means by which your voluntary services may be most usefully mobilized and amicably concerted in an enlightened and intelligently designed routine for the reduction of human suffering and for the most profitable use of available financial resources. Let me reaffirm my belief that you have, in addition to a moral obligation, a material interest to do so, more particularly as the hour is already late.