Population Trends in Relation to Health Administration [EN 7/61]

THE HON. MINISTER FOR HEALTH:

Attached is an important report and recommendation by the Commissioner of Public Health, which is recommended for your favourable consideration.

A laboratory such as that suggested seems to be an essential part of an important hospital, and the conclusions which might be reached following the research indicated, might prove to be a very great value indeed.

In the event of your approval to the recommendation it will be necessary for me to approach the Treasury for the finance necessary.

H. T. Stitfold

HTS/H UNDER SECRETARY

16.4.47

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UNDER SECRETARY FOR HEALTH:

I am in entire agreement with the report of the Commissioner and shall be glad if you will place his matter before the Under Treasurer with a view to the necessary finance being made available.

(signed)

MINISTER FOR HEALTH.

18.4.47

THE HON. MINISTER OF PUBLIC HEALTH:

Population Trends in Relation to Health Administration

The material increase in the expectation of life resulting from improved living conditions, health administration and medical practice, coupled with the serious fall in the birth-rate of recent years, has resulted in an alteration in the structure of the population.

In 1911 the age distribution of population was roughly as follows:

It will be seen that-

(a) By 1966 34% of the population will be aged 45 and over compared to 16% in 1911. Unless the birth-rate materially improves or the death rate rises the progressive ageing of the existing population will still further load the senior age groups.

(b) Broadly speaking, the productive and reproductive age group, 20 to 44, will in 1966 constitute but one third of the population compared with one half in 1911. During the subsequent 20 years it will be less than one third and its future will be determined by the birth-rate in the decades prior to 1966.

(c) Meantime the proportion if the aged and infirm age group, 65 and over will be more than 10%, a proportion four times greater than it was in 1911. At a time when there is agitation to raise the school leaving age and to lower the retiring age, to increase the amount of and entitlement to old age pensions, it is disquieting to note that the ratio of potential pensioners to the reproductive group has moved from 1 – 20 in 1911 to 1 – 5 in 1946, and is estimated to be 1 – 3 and still rising in 1966.

Social trends of this nature are beyond control of influence of the Department of Public Health. The Department can, however, and must, call attention to the need to provide for the care and comfort of the aged who have ceased to earn, and attempt to prevent the infant wastage associated with abortion, still-births, infant mortality and chronic invalidity following birth injury.

1. Aged and Infirm: The proportion of aged to the working group which must in years to come provide for them, is steadily increasing, and it may well be, if the birth rate does not improve, that at some not distant date the care of the aged and infirm will become such a responsibility and financial incubus upon the earning individual that he will violently reject it. It seems desirable, therefore, that provision for the aged and infirm should be made by the ageing themselves in anticipation of their ultimately requiring it, in other words, the cost of the ultimate provision for him should be levied during his productive period upon the future beneficiary.

These persons are not usually in good health, and even if normally in good health they frequently require institutional care.

At present they constitute an acute embarrassment in hospitals where they occupy beds for long periods with imminent risk of being discharged prematurely to make room for the acutely ill.

It is necessary to consider the adequacy or otherwise of provision outside hospital for these aged people at a time when housing shortage and the increased tendency to live in flats and tenements has made it difficult for the younger generation to care for its aged.

It is estimated that in 1966 there will be 57,000 persons aged 65 and over, compared to 6,656 in 1911.

In 1911 the State provided accommodation for 450 aged and inform at “Sunset”, a ratio of 1 – 15.

In 1921, when the population in this age group was 10,834 State provision remained the same.

In 1946, there was 38, 358 over the age of 65 in Western Australia. State provision for them totalled 630, a ratio of 1 – 61.

Clearly, attention must be given to the formulation of a policy in respect to the aged. Such a policy must embrace a wide field including such diverse components as age of retirement from earning, entitlement to pension and provision of accommodation.

2. Sterility: Childless married couples are unable with facility to ascertain whether some remediable cause is preventing conception. Few specialists competent to examine and advise them are available in Perth, their identity is known to but a few and their fees place them beyond the reach of many. Such couples, therefore, waste valuable time and sometimes considerable sums of money in seeking advice from medical practitioners neither competent nor equipped to conduct an exhaustive examination, or charlatans wholly unqualified to examine or advise.

A properly staffed and adequately equipped Sterility Clinic is a pressing need in the Metropolitan area, and if the principle is approved, a detailed plan will be submitted for consideration.

3. Abortion: There is quite considerable wastage by abortion. In the five months ending 19^th March, 1947, the Royal Perth Hospital alone notified 159 cases of abortion, approximately one thirtieth of the State’s births during the same period.

In the six months ending December, 1946, various Midwives have reported 42 cases. The aggregate figure must be regarded as but a small fraction of the State total.

Of the 159 cases reported by the Royal Perth Hospital only four were described as Therapeutic. Seven others were described as induced, presumably illegally, and the remaining 148 as apparently spontaneous, because insufficient information as to interference could be obtained by the Medical Attendant. When the Commissioner of Police was asked to investigate cases of abortion with a view to determining criminal interference, he intimated that his Department was only concerned where there was danger of death.

It is improbably that such a large number of abortions, in whom a proportion are healthy unmarried girls, should be spontaneous. If, however, they are, enquiries should be directed to the factors occasioning this spontaneity.

Attention should be given to:

• Research into the causes of abortion.

• Identification and eradication of social influences leading to and affording opportunity for criminal induction.

• Identification and correction of causes leading to spontaneous abortion.

4. Still-births: Still-births during 1946 totalled 293, an estimated rate of 24.3 thousand confinements. Regional analysis of this still-birth rate is not yet possible but in the first six months of the year the Metropolitan rate was 30.78 and the rural rate 17.52.

During 1945 the Metropolitan still-birth rate was 22.07 per thousand confinements, so that for the first six months of 1946 the rate in the city increased roughly 40 per cent.

Actual births during 1945 were 10,672 and during 1946 12,105. It will be seen, therefore that a substantial increase in the birth rate has accompanied the increase in the still-birth rate. Whether these observations are in any way related as cause and effect it is not possible at the moment to say, but the figures do suggest that the increase in the birth rate may have been directly associated with increased risk to the foetus in one or more of the following ways or in other ways.

(a) By the extension of births into a group of mothers at risk.

(b) By imposing upon busy practitioners and on over-worked nurses of under-staffed Hospitals a stress which prevented them affording all mothers pre-natal observation and care, adequate to permit their forecasting and avoiding obstetric risks to the foetus.

(c) By inducing overworked obstetric attendants to afford rushed and unsatisfactory attention at the time of delivery.

Maintenance of the present birth rate, even of a higher birth rate is a matter of first importance to the State and to Australia. It is the only effective demographic factor which can correct population trends at present threatening to convert the population into one predominantly senescent.

At present it is not possible to collect the full information regarding still-births necessary to elucidate their fundamental causes. Some information, however, is available from the records of King Edward Memorial hospital, where the still-birth rate for 1946 was 30.8 per thousand confinements. It should be born in mind in considering these figures that the experience of King Edward Memorial Hospital does not necessarily reflect the obstetric experience of the Metropolitan Area at large for the following reasons:

(a) Cases suffering from toxaemia and requiring special attention, are commonly sent to King Edward Memorial hospital by private practitioners and private hospitals before delivery.

(b) Cases of difficult labour are commonly sent to King Edward Memorial Hospital beforehand or during labour when they are found too difficult for the average practitioner.

At King Edward Memorial Hospital still-births during 1946 totalled 73, and were ascribed to, by percentage:

Viewed broadly the figures indicate that the high quality of specialised obstetric attention to patients at King Edward Memorial Hospital reduces foetal mortality from causes other than toxaemia and pre-natal foetal death to a relatively low figure. The death rate from difficult labour at King Edward Memorial Hospital is inflated by the number of cases arriving late in labour from outside sources.

Efficient pre-natal observation and care may be expected materially to reduce the foetal death rate from difficult labour, but research is required into the two fruitful causes of mortality which may indeed be one, toxaemia and pre-natal foetal death.

5. Neo-natal deaths: The magnitude of the loss of infant life through pre-natal and natal causes is not fully represented in the still-birth figure. A number of infants recorded as live births have been so influenced by the same pre-natal conditions as cause still-birth that they die shortly after birth and survive crippled, or presenting some less gross abnormality unfitting them for full and normal ultimate citizenship.

Analysis of Infant Mortality Statistics reveals that some 55% of all infant deaths during the first year of life occur during the first week after birth. The causes of these deaths are primarily those which play such a significant part in the still-birth rate, manly prematurity birth injury and inherent defect following abnormal conditions in utero.

Research into causes and prevention of prematurity, the avoidance of birth injury and the influence of maternal toxaemia is necessary to reduce not only the still-birth rate, but also the number of neo-natal deaths and the birth of crippled children.

Recommendation: It is recommended that approval be given to the appointment of a Special Committee to be known as the Advisory Committee on Infant Mortality, which shall sit with the Commissioner of Public Health for the purposes of:-

(a) Investigating the cases of sterility, abortion, still-birth and neo natal trauma.

(b) Preparing an ordered plan for Medical and Pathological research into the problems arising from its studies, and for the collection of such information as it desires for its purposes.

(c) Recommending to the Commissioner of Public Health measures to be taken by statute and otherwise for the purpose of assisting its researches and implementing prophylactic measures.

The Committee should consist of:

• A specialist obstetrician.
• A specialist Physician
• A Paediatrician
• A Pathologist
• A Serologist
• A Midwife.

The Committee should meet with the Commissioner of Public Health as Chairman and Convenor, not less frequently than once a month and should have power to co-opt for special purposes decided by itself.

In discussion with members of the medical profession, including possible appointees, I believe that members would be glad to serve on such a Committee in an honorary capacity.

The purposes of the Committee will require Serological, Bio-Chemical, Microscopical and Pathological investigations at King Edward Memorial Hospital which can only be performed in a laboratory by competent technicians. Such facilities do not exist at King Edward Memorial Hospital.

Every woman attending the Ante-natal clinic at King Edward Memorial Hospital should at least be submitted to Serological tests for the identification of syphilis and to Blood grouping to determine whether there is any incompatibility in paternal and maternal blood.

Attempts to have the first of these services rendered in the laboratory of the Department of Public Health have proved unsuccessful, particularly on account of the distance separating the two Institutions. Blood grouping has hitherto been undertaken by the Red Cross Blood Transfusion Service which has now intimated to the Commissioner of Public Health that it can no longer undertake this work owing to the strain imposed upon its resources by the increasing demands made upon it.

Serological and Bio-chemical investigation of the mothers is a measure of first importance in any plan attempting the reduction of still-births, particularly of those recorded as Toxaemia, Maceration or Premature. Reasonable prospect of success can only attend investigations undertaken as an ordered routine made in the Hospital itself.

Sufficient space to permit the establishment of a small laboratory is actually at the moment available at King Edward Memorial Hospital in the old building formerly used as an Infant Health Training School. Subject to installation of certain fittings making available water, waste connections, gas, steam and electricity where necessary, cost of furnishing and equipment is estimated at £1,000.

Staff is recommended to consist of an Honorary Pathologist, assisted by a technical and junior assistant. It is estimated that the annual salaries involved will be approximately £700 per annum.

The annual maintenance, provision of glass ware, chemicals etc. is estimated at approximately £175.

Approval, therefore, is sought for – 

(a) The preparation of an estimate by the Principal Architect for the installation of the necessary fittings to permit certain rooms at King Edward Memorial Hospital being used as a laboratory.

(b) Equipping of a laboratory at King Edward Memorial Hospital at an estimated cost of £1,000.

(c) The appointment of a technician at an annual salary of £450 to £486.

(d) The appointment of a junior assistant at an annual salary of £156.

(e) For maintenance expenses at the rate of £175 per annum.

Autopsy upon still-births in the Metropolitan Area should be made obligatory by law and should be performed in the laboratory at King Edward Memorial Hospital by the Honorary Pathologist who should report to the Committee through the Commissioner of Public Health. Autopsies on still births in the Metropolitan Area may be expected to total approximately 150 annually.

Dr. A.T. Pearson, Demonstrator in Anatomy at the University of Western Australia has intimated that he is willing to undertake the autopsies involved without fee, provided he is afforded adequate facilities at King Edward Memorial Hospital, that the cadavers are brought there for examination and that he is reimbursed travelling expenses estimated at approximately £250 per annum. For this purpose he could be appointed to the Infant Mortality Committee.

The legal enforcement of autopsy upon still-births and neo natal deaths may be affected by order of the Coroner or by amendments to the Health Act. Subject to your approval, and pending appropriate amendment of the Health Act, a memorandum for despatch to the Coroner through appropriate channels indicating the desirability for these post-mortem examinations can be prepared for you.

CE Cook
COMMISSIONER OF PUBLIC HEALTH

14^th April, 1947
CEC/PW