To the Hon. the Minister for Health:
The report on the Department of Public Health for the year 1948:-
ADMINISTRATION: Administrative Inadequacy
One cannot escape the conclusion that effective health administration is seriously impeded and the extension of activity into new fields largely frustrated by the out-moded and irrationally devised establishment of the Department.
In the past the apotheosis of the lay administrative officer and the traditional reliance upon him to determine the scope and design of the Department, have developed a structure which, though doubtless in harmony with Treasury and Public Service pre-conceptions, is ill-adopted for its avowed purpose and alien to the technical requirements.
The functions of a Department of Public Health should be-
- To study the incidence of disease and the causes of morbidity and mortality in the community.
- To identify factors which are preventable and to devote itself to removing them.
- To conduct research into improved diagnosis and methods of treatment in order to shorten the period of illness, avert a fatal outcome or mitigate the effects of innumerable lesion, and actively to engage in extending the knowledge of and facilities for the universal application of these,
Health Departments as at present constituted are largely the unplanned growth of bodies originally formed to control morbidity and mortality during the last century when the herding of population in cities following the industrial revolution led to the recognition that filth and squalor were important agents in the transmission of disease and when the epidemiology of infectious disease was but imperfectly understood.
These bodies since their original establishment have contributed materially to the control of morbidity and mortality from the filth and infectious diseases, but owing to their origin and to their traditions, the training of the staff and legislation under which they operate, tend to emphasise the importance of waste disposal, drainage, ventilation, quarantine and disinfection. Their procedures are largely outmoded and even archaic when studied in the light of modern advances in our knowledge of immunity, epidemiology and therapeutics,
It is true that from time to time the influence of other factors, industrial hazards for example, in contributing to morbidity and mortality, has become so obvious in modern civilisation that attention has sporadically been given to extending the scope of public health departments into the newer fields.
Speaking generally, however, the long pre-occupation of health departments and their staffs with the narrower field of sanitation and infectious disease control has contributed to these new functions being vested rather in specialists evolved independently in the occupations and industries affected.
In Western Australia this trend has been even more marked than elsewhere, even such conventional public health activities as sewage disposal, the control of water supplies, the marketing of milk, bread manufacture and industrial hygiene having been vested in other departments of Government unprovided with trained medical staff.
Over a long period the inadequate professional staff of the Health Department has been pre-occupied with traditional sanitary routine and its predominantly lay organisation has received or responded to no inspiration from contact with medical practice and advances in medical knowledge.
Meantime the medical practitioner actually in contact with disease has become accustomed to leave prevention to the organisation provided for that purpose and has devoted all his attention to curative medicine and to encompassing the many rapid advances made in this field in recent years.
The local health authorities upon whom lies the responsibility of administering the Health Act in local areas are in consequence deprived of advice or inspiration from medical practitioners with a high sense of public health responsibility or adequate knowledge of modern methods of control. Under the general influence of a static central authority and lacking trained admonition, they have gradually fallen into a retrograde and outmoded routine hardly to be differentiated from negligence.
The subjoined graph [on diseases by mortality rate] will at a glance reveal the progress of the major killing diseases since control by a department of public health has been undertaken. They show that those diseases which are largely associated with filth, contaminated food and polluted water have been substantially reduced until from being important agents of morbidity and mortality they are now comparatively unimportant.
A new field for an efficient and re-organised Health Department is disclosed. The graphs show that there are a number of causes of death apart from those directly associated with the ageing of the population, to which a re-organised health Department might profitably devote attention. For this purpose, however, it would be essential to establish the Department on a basis where there was the closest liaison between the administration and the practising medical profession. This is a field of activity not generally or effectively hitherto undertaken by a health department, but is a logical function already cited in (c) above.
Effectively to embrace this wider field, the Central Health Authority will require the close co-operation of every medical practitioner throughout the State, more particularly for the purpose of:-
- Assuring a high standard of ante-natal care and midwifery practice,
- Maintaining adequate medical supervision of the pre-school and school child.
- Assuring a progressively higher standard of medical practice, the collection of such statistical and clinical information as may be required for purposes of research and organising the early and universal application of improved methods of diagnosis and treatment.
- Ensuring the discharge of public health obligations in association with this medical practice at consistently high level of efficiency and uniformity.
It will also require constant access to specialist advice in all branches of medicine, but particularly in paediatrics, obstetrics, medicine and surgery. The State can ill afford to appoint such advisers on a salaried basis to its Health Department staff, but they are accessible in the community itself, and are doubtless willing to serve the State whenever required. It remains but to provide the organisation through which this advice may be obtained.
The Health Department must obtrude prominently into the field now administered by the Medical Department, a lay administration nominally advised by a Principal Medical Officer who has no prescribed function and no defined authority.
It is recommended, therefore:-
(a) That the Department of Public Health and the Medical Department be united as a Department of Health. The Department of Local Government, the Department of Native Affairs, the Child Welfare Department and the Shops and Factories Department, have many points of close contact with health administration and require specialist advice and guidance. Unless this is to be provided for them independently it would be well to integrate these Departments closely, preferably under one Minister.
(b) That the Local Health Authority – whether Municipality or Road District – in its own area or in co-operation with adjacent areas, undertake health and hospital administration under the supervision and direction of the Department of Health.
(c) That there be established a Health Council of which the functions should include:-
- Discussing of and recommendations regarding factors of morbidity and mortality.
- The organisation of medical practice both in its preventive and therapeutic phases.
- The initiation of such public health and hospital legislation as may be necessary from time to time to establish the health and medical organisation on a secure basis.
- To serve as a liaison body between the Government and the medical profession.
- To give the medical profession an effectual voice in health and medical organisation.
- To serve as a co-ordinating body organising the medical profession in public health and medical practice within the State.
(d) This Council which should have power to co-opt for special purposes should include four specialists, namely a physician, a surgeon, an obstetrician, a paediatrician elected by their specialist groups, two general practitioners elected by the British Medical Association; a layman representing hospital administrators; and a layman representing the Department of Local Government. The Council should be chaired by the Commissioner of Public Health and its Secretary should be a public servant in the Department of Public Health.
It is important that the professional persons appointed to the Council shall be-
- Spokesmen of their professional categories.
- Themselves specialists of the highest qualification.
To achieve the first purpose it is desirable that they shall not be selected by the Minister, but shall be the elected representative of their groups.
(e) As opportunity offers local authority areas individually or in regions might as appears necessary be provided with subsidiary committees similarly constituted.
These local committees of professional and executive members would be responsible for implementing in their areas the policy of the Council.
Routine administration throughout the State should continue to be conducted by the Department of Health under the professional guidance of the Council, and in local authority areas by municipal councils and roads boards under direction of the Department.
Enlightened health control in our time has become a function of the practising medical profession in all its branches. The system here outlined is calculated to mobilise the forces in contact with disease, to study and control it so that this function shall not continue to be vested in a detached administrative body largely guided by outmoded tradition and an atavistic outlook.