by Dr C.E. Cook, C.B.E. 4th August, 1958.
Your meeting tonight has been made the opportunity to inaugurate the Elkington Oration which your Queensland Society of Health intends shall become an annual occasion to honour the memory of John Simeon Colebrook Elkington and to commemorate his outstanding service to Public Health and Preventive Medicine in Queensland and in Australia. Your invitation to me to give the first of these orations has imbued me with a deep sense of responsibility. I recognise a twofold obligation to do justice to the subject and to justify the signal honour implicit in the invitation. In my youth, Elkington was conspicuous amongst a few masters in preventive medicine who by precept and example inspired and stimulated the imagination of a number who like myself subsequently chose to undertake medical service in the Australian tropics. In my own case he was also the actual means by which I was afforded the opportunity to realise the hopes and ambitions which his example had stirred in me. To him I personally owe an enduring debt of gratitude for inspiration, advice, encouragement and practical aid. I am sure that amongst those old enough now to have served with him there will be many who will acknowledge a like indebtedness.
I feel that your Committee has been prompted by the inspiration of genius in deciding that your young organisation shall, each year, enjoy the opportunity for rededication offered by an annual oration bearing Elkington’s name. As you review your work for the year just passed and as you plan your objectives for the year ahead, you will have the opportunity, as it were, of appraising these against the exacting standards set by the master. Each year the renewed appreciation of his achievements will serve as if he were your present patron, to inspire, encourage and assist you in your enterprises. Each year too, the magic of his name should attract for you speakers of ever greater experience, importance and ability to stimulate you and to give a dynamic vitality to your association.
Elkington entered the field of Public Health and Preventive Medicine in Australia early in this century when he took over from a lay authority Public Health Administration in Tasmania. At that time although health administration was nominally vested in the local authority, he found that two thirds of his health authorities lacked the services of a medical officer of health and only one third had appointed sanitary officers. Half the local boards and Councils and 14% of Town Boards had no Sanitary By Laws. 38% had no rating power and were local Boards of Health only in name. The burial of night-soil in close proximity to dwellings was permitted in two-thirds of all the local authority areas of a population exceeding 500 souls.
It is not surprising that the principal causes of death in those days were bowel infections, respiratory infections and tuberculosis in that order, or that the infant mortality rose in one year as high as 120 per thousand live births. At this time too bubonic plague was endemic in Australia and smallpox from time to time.
Elkington set himself to repair the deficiencies in the existing Health organisation and to provide the local and central health authority with the necessary powers and staff to function adequately. He was particularly concerned to improve the conditions under which food was manufactured, prepared, and offered for sale, and to this end introduced a Pure Food Act and Regulations and established a Central Food and Drug Analytical Laboratory. He supplemented the basic sanitary provisions of the existing Health Act by legislation to assure the purity and protection of domestic water supplies to control offensive trades and to provide for the strict supervision of milk production and sale. As measures directed towards improvement in infant mortality, he secure the passage of a law requiring the early notification of births, and gave close attention to education in infant feeding and the protection of infant food.
Moving to Queensland in 1910 he continued his active campaigning for the setting up of adequate and competent local health authorities equipped with the powers necessary for their efficient functioning. He early revealed his interest in and concern for the control and eradication of tropical disease, establishing in North Queensland a branch office of his Department to ensure that the special problems of the area should receive the direct and informed attention they demanded. He appointed a special staff under the guidance of an entomologist to undertake large scale mosquito eradication campaigns. He opened a special hospital for leprosy at Peel Island in Moreton Bay and undertook personally a study of the medical and sanitary requirements of the native population in the islands of Torres Strait. He gave early attention to the arrest of the spread of typhoid and for this purpose supplemented improved measures of sanitation with mass immunization in the epidemic areas.
In Queensland as in Tasmania he secured the passage of an Act providing powers for the strict supervision of manufacture and sale of food. He inaugurated the schools medical service, commenced the registration of nurses in Queensland and arranged for an improved course of training for health inspectors.
In his own words when retiring in 1913 from the office of Commissioner of Public Health, Queensland to join the Commonwealth Service:
the policy of the Department has been directed towards laying a foundation upon which there may be erected an enduring sanitary super structure ….. the old empirical “clean-up” policy no longer holds its former place as the first and vital step towards sanitary safety…..It will apparently be a long time before it becomes generally recognised that the function of a Department of Public Health or local authority is not that of abolishing stinks, clearing choked drains, removing dead animals and cleaning up backyards.
He repeated as he had emphasised year after year that the real road to safety lay in such special undertakings as food analysis, strict supervision of the manufacture and sale of food, systematic warfare against tuberculosis and the social and structural conditions favouring it, detection and control of the carrier of infectious disease, eradication of vermin conveying disease to man, provision of the means for the accurate investigation and prevention of disease and education of the people by every available method in the aetiology and prevention of disease.
With his transfer to the Commonwealth he devoted his energies and capacity for detail to developing and perfecting the quarantine procedures which have with such conspicuous success prevented the introduction of quarantinable disease to Australia.
In retrospect the most striking features of his service in Tasmania and Queensland are the wide diversity of problems to which he gave attention and the imposing number of remedial measures he so rapidly applied. Indeed it is evident that whilst he was an unsparing critic of the deficiencies of health administration as conducted in his day he clearly perceived how these were best to be remedied. Not only did he devise the measures necessary for this purpose but himself made the opportunities for incorporating them expeditiously in both statute and field practice.
The conditions evoking the sharpest of his criticisms were those attending inefficient health administration by bodies of persons untrained and unprovided with a legal code sufficiently comprehensive to give direction, purpose and authority to their decisions. Particularly did he condemn the narrowness of view which confined the practice of preventive medicine within the limits of domestic sanitation. With these thoughts in mind let us attempt to appraise the adequacy of public health administration in Australia in our own time as he might have done.
Public Health Departments in the Australian States have been organised upon the only partly correct assumption that infection is to be controlled by cleansing of the environment. The emphasis on sanitation, domestic and communal, made it inevitable that responsibility for administration of the Health Acts and their Regulations would be vested in the local authority.
Local authorities have provided themselves with inspectors and adopted by-laws more or less effectually policed, designed to remove these conditions of squalor, filth, overcrowding and insanitation regarded as likely to cause or contribute to the spread of disease. These cleansing and scavenging measures by improving sanitation and permitting induction of the individual to a higher standard of living, have in fact played a notable part in the reduction of disease. In most areas however the limit of their usefulness has already been reached and diseases for the control of which these measures were taken continue endemic with exacerbations of incidence from time to time.
Measures intended for the prevention of disease must provide for the vagaries of personal behaviour and include education of the individual in his responsibilities to the community. For example, at todays improved standard of communal life there should be no risk of fulminating epidemics of bowel infection originating in polluted water supplies or other gross communal insanitation. Nevertheless in spite of the ultimate in hygienic sanitary equipment, complete elimination of the risk of infection is not to be achieved by this means. Neglect of the elementary principles of cleanliness on the part of a carrier will spread infection by the water supply and sewerage systems never so infallible.
There are in parts of Australia potentially malarious areas where climatic and economic conditions render mosquito control utterly impossible. Control of malaria here must be attempted by radical cure of the case and eradication of the parasite from the carrier. This method of control is completely dependent upon the intelligent and spontaneous co-operation of the patient and his adequate instruction in his responsibilities to the community.
Such change as there has been in public health organisation in Australia during the last half century has involved reduction rather than extension of the powers and responsibilities of the Central Health Authority. This is perhaps a direct and inevitable result of selecting the local authority as the Health Department’s agent in the field. For example in some States supervision and direction of the local authority even in its public health responsibilities have been transferred to the Departments of Local Government. Specialist departments have taken over the provision and protection of water supplies, deep drainage, the control of production and marketing of milk. Aspects of industrial hygiene have become the immediate concern of the Department of Labour and Industry or its equivalent. The Department of Agriculture has assumed responsibility for the control of slaughtering and the marketing of meat.
In Queensland, alone of the Australian States, has the central health authority contrived to retain the responsibility and opportunity for supervising and directing most of the sanitary measures originally designed to converse the public health.
I have no doubt that this preservation of the public health interest was in no small measure due to the influence of Elkington and the school of thought associated with him.
To my mind the danger of these diversions lies in the separation of the Health Authority from direct control of measures and installations primarily intended for the preservation of health and the transfer of these to the control of a Department whose prime function is, perhaps, the advancement of an industrial interest. I believe there must inevitably and always be a conflict of values in this situation and the probability of subordination of the health interest by officers who are not sanitarians.
This possibility acquires added importance from the modern trend in certain States to place authority in the hands of the layman rather than of the specialist. In an age of specialism the individual who lacks advanced training as an expert in some special field is apt to gravitate to a position of subordination. There must of necessity be, in any organisation or enterprise, large numbers of these to conduct the ordinary accounting and clerical duties so necessary for efficient administration. Confronted with a future of subordination to specialist and professional colleagues, clerical officers have in self defence it seems resorted to the elevation of administration to the status of a speciality, creating the fiction that theirs is the function of first importance. I suggest to you that however important administration may be it must always be the servant and never the master of policy. In a Health Department policy must be decided by the trained sanitarian.
As an example of the subordination of health principles to Departmental policy under these circumstances, perhaps no better example can be quoted than that of bread. All will agree that this staple food is handled and delivered to the householder under conditions well calculated to involve gross contamination with pathogenic bacteria. None will dispute that the risks involved could be materially reduced if bread were cleanly wrapped, as the law required other articles of food to be. Why then is bread not wrapped? Briefly because bread must be wrapped cold and after baking requires some hours to cool. Statutory requirements for the hours of labour for bakers and bread carters fixed by the Department of Labour and Industry or its equivalent will not permit this cooling period. Fresh bread therefore must be delivered unwrapped and wrapped bread is likely to be 24 hours old.
At the beginning of this century the three principal causes of death were typhoid and bowel infections (17.7% of all deaths) respiratory infections (11.3%) and Tuberculosis (8.5%); heart disease (6.8%) and cancer (3.9%) were less important.
Today, by contrast, diseases of the heart (28.7%) are responsible for more deaths than any other cause, cancer (13.2%) ranking second.
The change, of course, is only in part attributable to improved sanitation under the direction of the Local Health Authority. The virtual displacement of the horse by motor transport has removed from centres of population a source of fly breeding with which local authorities were powerless to cope effectually. Immunisation, improved methods of diagnosis and treatment and above all the universal advancement in the knowledge of infant care have all played their part.
In Queensland in 1903 the infant mortality reached 120 per thousand live births. We must suppose that in those days the community with what grace it could accepted the proposition that one of every eight children born each year would die before attaining the age of twelve months. It is a sobering thought that we in our turn may have no better ground for accepting today’s infant mortality at 22 per thousand live births as satisfactory.
Marked as the improvement in the national health has been, much still remains to be done. The major causes of death to-day are not to be prevented by methods immediately ready to hand and it is difficult to see how the local health authority as at present constituted could engage in the research required to ascertain what measures of prevention can be devised. Nor does it seem likely that the local authority could usefully be employed in applying these measures once they have been identified.
I think you will agree that the functions of a modern Public Health Department must include –
- the study of the incidence of disease and of the causes of morbidity and mortality in the community,
- identification of the factors which are preventable and the removal of these, and
- the initiation and encouragement of research into improved methods of diagnosis and into therapeutic measures calculated to shorten the period of illness or to avert a fatal outcome, dissemination of this information and the provision of facilities necessary for its universal application.
However appropriate the local authority as a supervisor of sanitation, it is clearly unequipped for and unadaptable to any major role in a system of preventive medicine based upon these principles. Even for its conventional role the local authority has required to be provided with a rigid code of procedure the purposes of which are not always clearly understood and in the application of which a wide and irrational discretion is often exercised.
To discharge its functions the Health Authority clearly must operate in the closest accord with the practising medical professions. Indeed the practitioner must be an integral part of the organisation created for the prevention of disease. He alone is in direct contact with the patient, he first and he alone is in a position to identify the disease, to notify it and to collect and supply the information required for its study. He as the agent of the Health Authority in contact with disease must be provided with the means of prompt and accurate diagnosis and effectual treatment.
I suggest, for your consideration, that in a properly organised system of preventive medicine the Central Health Authority would rely upon the medical practitioner to provide a considerable body of information from his practice. The information would be collated and studied and lessons derived from it systematically relayed to the practising professions for guidance. Practical aid for the practitioner in this co-operation may well become obligatory and this may extend to the provision of technical and possibly even clerical assistance.
Apart from the problem of the major killers a number of conditions unimportant or unrecognised at the turn of the century demand attention today.
Throughout Australia we have in recent years experienced unexplained epidemics of pyrexia with diarrhoea and vomiting. Amongst aetiological agents suggested for these have been viruses, staphylococcal toxins in the pasteurised milk, haemolytic streptococci. The recent demonstration that salmonellae pathogenic to man can be transmitted from infected poultry through the egg to dried egg pulp and other egg products raises the question whether some of these outbreaks may not in fact have originated in the consumption of insufficiently cooked infected egg. One wonders whether the attempt should not be made by Departments of Agriculture to eliminate salmonella infections from poultry farms by measures comparable to those so successfully employed in the eradication of tuberculosis from dairy herds. Meantime no local health authority concerns itself unduly with the protection of poultry from infection by rats, pigs or household wastes.
Amongst causes of illness incapacitating from work, virus diseases have assumed an unprecedented prominence. Coxsackie, A.P.C. and ECHO viruses in addition to species known for many years are now recognised to cause a variety of maladies ranging from transient pyrexia and muscular pain to encephalitis and possibly death.
We are becoming increasingly aware of the importance of the zoonoses. Leptospirosis, Q. fever and typhus unidentified when Elkington presided at the Health Department here have since been carefully studied and are now reasonably familiar to medical practitioners in the area of their prevalence. New interest attaches to toxoplasmosis and the mycotic zoonoses torulosis and histoplasmosis, now demonstrated to attain a much higher incidence in animals and man than has hitherto been suspected.
Conspicuous amongst the complex and unsolved problems to-day confronting the health authority is the conservation of the antibiotic as a valuable therapeutic agent. The role of the antibiotics in the spectacular relief and cure of disease for which, before their introduction, the medical profession had no specific or reliable remedy is well known. It is not so well known that antibiotics have three attributes which detract from their present and future value:
- Pathogenic bacteria are able to develop resistance to most of them. In inadequate dosage the antibiotic fails to eliminate the more resistant strains and with the survival and multiplication of these value of the antibiotic as a therapeutic agent is progressively reduced.
- Dosage with an antibiotic may produce sensitisation in man. This sensitisation may be sufficiently serious to endanger life when the same antibiotic is used again.
- By elimination certain susceptible strains from the complex bacterial flora of the human body, an antibiotic may upset the existing equilibrium and permit pathogenic organisms hitherto held in check to proliferate and cause disease.
These three attributes derive importance from the use of antibiotics in the hands of physicians, veterinarians and the primary producer.
Medical practitioners confronted with an acute febrile infection are apt to prescribe antibiotics immediately, perhaps without waiting to arrive at a precise or even any diagnosis. In justification of this practice it is argued that the patient and his most expeditious return to health and work is the purpose of his seeking medical advice and treatment. The medical practitioner is said to be under a moral if not an economic obligation to attempt his immediate cure instead of prolonging his illness while he reaches a diagnosis and selects an appropriate treatment. Whatever the ethics of the matter a large proportion of cases so treated will return to normal health – some because of the antibiotic was in truth an appropriate remedy, many because no treatment was in fact needed. In the first group some and in the second group all who have taken the antibiotic will have done so unnecessarily and amongst these:
(a) a proportion may be sensitised so that a later dose perhaps necessary to save life may prove dangerous and even fatal.
(b) There will have been a selection of resistant organisms so that the number of these will have increased relatively to the whole.
Many practitioners mistrusting or neglecting strict asepsis have developed the practice of using antibiotics prophylactically. The resulting increase in the prevalence of resistant organisms, particularly staphylococci is a problem increasing urgency and magnitude.
It may be remarked that there are two considerations which rather invalidate the argument of urgency advanced by the profession in support of blunderbuss antibiotic therapy. If the disease is one in which the antibiotic has no value, its exhibition is not only wasteful but by postponing appropriate treatment may actually delay recovery and indeed endanger the life of the patient. Consider for example the use of an antibiotic in undiagnosed malignant malaria. Even where the antibiotic is in fact the correct therapeutic agent, its empirical use without prior precise diagnosis is objectionable in the view of the health authority because cure of the patient without correct diagnosis may prevent recognition of the early cases of an epidemic and by this concealment lead to the involvement of a number of secondary cases which might otherwise be prevented.
The lavish use of antibiotics by veterinarians and farmers is attended with the same risks of sensitisation and bacterial resistance. The unrestricted use of penicillin by farmers in the treatment of mastitis is now generally admitted to be associated with two real dangers for man – sensitisation of and the evolution of penicillin resistant strains in the consumer. The co-operation of the Department of Agriculture with the Health authority is required here to control the dosage used, and to ensure the withholding of the affected milk from market for at least three days. The use of antibiotics in agriculture as growth accelerators and in industry as a means of preserving meat, poultry and fish has immeasurably increased the risk that these therapeutic agents will lose much of their value as a result of the selection of resistant organisms.
Another problem created by agriculturalists for the Health authority attends the use of hormones especially sex hormones. These are extensively used as growth accelerators in the poultry industry and chemical wholesalers are of course anxious to expand sales by introducing their use to other branches of farming. Uncontrolled use of these hormones is not without risk to user and consumer alike and if general approval is to be given to the practice, strict and effective policing will be necessary in the interests of the public health. This policing dictated and required by the health authority must presumably be provided by the Department of Agriculture.
New and extremely toxic pesticides are being used in the protection of food crops from spoiling by insects. The use of these poisons involves hazards for the operator applying the pesticide at the farm or garden and Health Departments have endeavoured to arrange for appropriate precautionary legislation. Under present conditions, any such legislation must be provided and policed by Departments of Agriculture.
There remains the hazard of the toxic residue on the food produced. Departments of Health will be concerned to make laws prescribing a tolerance for each pesticide which must not be exceeded in the product as presented for sale. The powers of the Health Authority will of course be limited to random sampling during the marketing of the produce, condemnation of that in which the tolerance is exceeded and prosecution of the vendor. This is manifestly an unsatisfactory method of protecting the public. More effectual action is possible to the Departments of Agriculture who can advise, prescribe, and to some extent supervise methods of application which whilst effective for the purpose intended will permit the product to be marketed in a condition satisfactory to the requirements of the Health Department.
I feel there may be a fundamental conflict of interest and policy in the respective viewpoints of the Health authority and the Department of Agriculture in such matters. Whereas the former is concerned only with protection of the consumer from natural or artificial hazards to health associated with agricultural produce, the latter has a sympathetic interest and possibly an unconscious bias towards advancing the sale of the product. New methods of chemical pesticide control, new techniques of antibiotic and hormone dosing of farm animals designed to minimise loss, increased output, or accelerate maturity are apt to be fostered and extended by the Department of Agriculture. There may be a difference of opinion between departments on the degree of danger involved where the risk is difficult of demonstrable proof. The Department of Agriculture actually in contact with the grower himself will be reluctant to embarrass him or to confront him with increased costs by imposing safeguards or restrictions which may be argued in a large proportion of cases to be over strict. On the other hand the Health Department is concerned with that small proportion where negligence proves dangerous or fatal. In its own field the Health authority will be anxious to impose a limit for residues of these toxic pesticides in food sold for human consumption. The Agricultural Department may object to the limit proposed on the ground that it would be difficult to police or embarrassing to the grower whilst the danger is not certainly demonstrated. These difficulties must be resolved and it is clear in these times there must be the closest and effective co-operation between the two Departments.
The time has arrived for the Health Department to review with courage and resolution its official attitude to smoking. Most States include in their regulations for the prevention of contamination of food a provision prohibiting under penalty smoking in any place used for the manufacture preparation or delivery of food. Incidentally it may here be remarked that in this context smoking in some States is classified with spitting and urination. Nevertheless it has almost universal practice to tolerate cigarette smoking in cafes, dining rooms and elsewhere during the serving and consumption of meals. As a pipe smoker I have never been permitted to smoke in an aircraft or public eating house. However I have been required to endure at mealtime with the best grace I may, the filthy pollution of the circumambient air by cigarette smokers graciously accorded this privilege by authority. If a Health Department is concerned to prevent the adulteration of food and the pollution of water why is it not interested in preserving the purity of air? Why may the cigarette smoker with unabashed vulgarity arrogate to himself the unchallenged right to ruin the meal of others at his table in a public dining room by flooding the atmosphere in his vicinity with the revolting stenches that nowadays pass for the fragrances of tobacco smoke. Now that there is a reason in the interests of public health to advocate and encourage abandonment of the habit of smoking, the tyranny of the smoker should be overthrown and he should be revealed for what he is, a spiritless slave to an objectionable addiction. Today more than ever the Health Departments have an unquestioned obligation to protect the non-smoker from annoyance and to assist the ex-smoker through his period of instability by prohibiting smoking in eating houses.
I believe too that Health Authorities should without more delay take cognizance of the increasing sale of filter tipped cigarettes. Although it is true that no claim is made for filters by the manufacturer I think we would be ingenuous indeed if we did not admit that the consumer believes that in some way they afford him protection from the carcinogenic qualities alleged to exist in cigarette smoke. How many people are deterred from making the final break with tobacco because they believe there is some protective virtue in these filters? I believe it is incumbent upon Health Authorities in the interests of these people to ascertain and to state publicly what purpose, if any is served by these filters, and to set standards of efficiency for those permitted to be marketed.
To meet some at least of these problems a health organisation which relies upon the administration of codified sanitary rules by a local authority is certainly now inadequate. Whilst there must be at all points of health administration medical inspiration and direction there must of necessity also be the closest co-operation between the health authority and the practising medical and veterinary professions in the diagnosis, treatment, recording, study and prevention of clinical disease whether apparently communicable or not. The provision of some special organisation for this purpose within the health authority cannot I believe be long delayed. If its development involves evolution of a new relationship between medical practitioner, the veterinarian, the agriculturist and the health authority, the sooner initial steps are taken to identify and activate the operative factors of this evolution the better.
As my contribution this evening to the memory of a great sanitarian, I have endeavoured to provoke you to view with an attitude of detached criticism such as his the problems that confront you and your methods of handling them.
In closing let me give you for your future guidance as a society a message chosen from a report written by Elkington over half a century ago:
Incomplete measures in preventive medicine are a serious source of danger
to the common weal since they give a delusive sense of security
and thereby invite disaster.
One of the delightful features of the Annual Meeting was the fact that Mrs. I. Elkington, wife of the late Dr Elkington whom the Society honours in its oration, was able to be present. She was driven from Mooloolaba by Sir Raphael Cilento, who was a great friend of Dr Elkington.
Those members who were fortunate enough to meet Mrs. Elkington were charmed by her gracious manner. After the Oration, Mrs. Elkington presented Dr Cook with an inscribed silver tray and she received a bouquet of flowers from Dr Jean MacFarlane.