A submission to the NHMRC Public Health Committee by Dr C.E. Cook
The Committee is asked to consider and pronounce upon the following propositions:-
- There is a wide and important field of preventive medicine beyond the sphere of conventional health administration as applied under Public Health legislation in Australia.
- In this field measures of control must rely principally upon prompt and accurate diagnosis, early identification of aetiological influence and enlightened study of their mode of operation, correct and complete treatment, and in some circumstances post-therapeutic review.
- This work can only be undertaken by members of the practising medical profession individually and collectively.
- In order that the profession may conveniently and successfully undertake this work it will be necessary to develop a form of organization which comprehends the medical practitioner as the executive unit in his practice.
- With the increasing financial interest of Governments in the treatment and therefore in the prevention of disease it may be considered only a matter of time before the creation of such an organization becomes an administrative necessity and a political objective.
- It is preferable for the medical profession itself to proclaim the value of and necessity for measures of preventive medicine in this field. It should acknowledge its own responsibility for providing the means of applying them and take the initiative in setting up the necessary organization and in devising its operative methods.
- In the alternative, government agencies may impose for this purpose official duties and obligations upon the medical practitioner and may be tempted to enforce satisfactory performance by economic pressure.
- The Committee agrees there should be an undertaking to co-operate in setting up an organization for the participation of the medical profession with the health authority in the planning and application of new and improved methods of preventive medicine.
- This organization would be based upon the general practitioner as the agent of the Health Authority in his practice. It would provide:
(a) A Committee in Preventive Medicine at Commonwealth level to advise and report to the National Health and Medical Research Council.
(b) A similar body at State level to advise and report to the State Health Authority.
(c) Regular local conferences of general practitioners in areas of common interest and ready accessibility to discuss proposals for measures in preventive medicine whether on initiative of individual general practitioners or proposed by the Health Authority.
These conferences would be called by a Convenor who, for the area concerned, would be the channel of communication between the State Committee in Preventive Medicine and the individual practitioner in all matters under discussion.
In attached papers and in those already circulated there are given examples of projects in Public Health and Preventive Medicine wholly dependent upon the medical practitioner for their proper performance; these are instances only and not to be regarded as comprehensive or limiting the field of co-operation with the health authority.
It will be clear that an increasing volume of clerical work will be imposed upon the practitioner as the organisation develops. To meet this situation arrangements for reimbursement of the practitioner for extra clerical service provided or the appointment of permanent clerical staff by the local or central Health Authority to serve groups of practitioners may become necessary and desirable. Such a development will permit the practitioner to serve in a much wider field of preventive medicine that is at present possible.
The organisation proposed provides the means for initiating discussing and deciding upon such a development.
- RELATIONS WITH THE HEALTH AUTHORITY
The official relations of the general practitioner with the Central Health Authority and with its medical officers leave much to be desired. There is little personal contact between the departmental medical officer and the general practitioner. Communications passing from the Department to the practitioner are apt to be requests or directions for the undertaking of a task which the practitioner is reluctant to perform or couched in disciplinary or minatory terms following omission of a statutory duty. In the result there has developed in the practising profession an unhealthy attitude of suspicion and contempt for the salaried medical officer whose routine office duties are believed to deprive him of any opportunity to appreciate the realities of clinical practice. On the other hand the medical officer has often reacted by regarding his colleague in practice as unco-operative in the prevention of disease, uninterested in public health and ill-informed in requirements of sanitary law.
Local Authority Health Inspectors complain that the hostile and obstructive attitude of the medical practitioner is commonly the greatest problem confronting them in discharging their official duties. On behalf of the medical practitioner it may be argued that the methods of preventing the dissemination of disease practised by the Local Authority and applied by the Inspector may appear of little value, outmoded, even perhaps suspect. Nevertheless they are required by law and it cannot be denied that the only full time worker in hygiene in a community is entitled to expect, from the medical practitioner, support rather than derision and obstruction. The medical practitioner himself may well be wrong in his judgement but this will not be realised by his public. He must remember that his opposition may well serve an inefficient and frugal Health Authority as pretext for discontinuing all effort to improve sanitation. There is clearly an obligation upon him as one himself trained in aetiology and prevention of disease to advise and guide the Health Authority and where necessary to initiate and press for amendments of the law. This he may feel he is not at present in a strong position to attempt.
The organisation proposed would integrate the practitioner into an organised system of preventive medicine. He would be kept fully informed of the decisions and policy behind public health and local government sanitary measures. He would have ample opportunity to challenge the value of outmoded procedure and to call attention to problems created and deficiencies disclosed by their application within the area of this practice. The departmental officer instead of appearing an impractical meddler serving no useful purpose and lacking any appreciation of the exigencies of practice would become a colleague with whom regular and thorough exchange of views would be found of much interest and value.
- SUPPLY OF INFORMATION
(a) Certificate of death from Cancer
(i) Statistical studies of cancer have included an attempt to assess from certificates of death the frequency of different types. The Commonwealth Statistician now proposes to discontinue these attempts and to leave statistical studies of cancer to those conducting cancer registries. The reason for this step has been that medical practitioners in certifying death from cancer have failed to specify type.
(ii) Statistical studies of the cause and incidence of cancer of the lung are largely frustrated by the circumstance that the lung is the site of metastatic new growth. Failure of medical practitioners in certifying death from cancer of the lung to state whether the new growth is primary or metastatic seriously impairs the value of statistics.
(b) Notification of Disease
Notification, perhaps with considerable clinical and social detail, is an essential ingredient for the study of prevalence and aetiology of disease and for the planning of effectual measures whether for prevention or for relief. Disclosure of the patient’s name and address to permit the prompt performance of statutory measures of control – isolation, disinfection and the like in the case of infectious disease – has become relatively unimportant with the decline in the incident and mortality of these disease and with the development of more effectual therapeutic and preventive measures.
The value of notification today is chiefly for administrative, epidemiological and statistical purposes. The importance of these uses is not always apparent to the general practitioner and there has developed a reluctance to take the trouble to notify when no useful purpose is seen to be served by doing so. Omission to notify either from negligence or from motives of obstinacy have impaired the value of epidemiological and statistical studies.
Now with the urgency of notification of name and address as an essential pre-requisite to preventive action no longer exists in respect of many diseases, disclosure of identify may no longer be necessary. It may be argued of course that the individual availing himself of a National Health Service may be required automatically to surrender the right of anonymity in the interests of the service. On the other hand it should still be possible to devise a method of notifying anonymously where house and personal preventive measures do not depend upon the fact of notification. The main objection of anonymity is the risk of confusion, duplication and oversight. If the system of notification is properly devised and conscientiously applied this objection might well be overcome.
In such matters, an organization of the type suggested could:
(a) provide a forum at which practitioners, statisticians and academicians could together discuss and reach agreement upon the scope, value and purpose of information to be collected by the practitioner
(b) provide a means for informing the practitioner upon the detail of information expected to be supplied by him and upon the reasons for it and give an opportunity of fostering his co-operation and good will.
3. STUDY OF DISEASE
(a) Zoonoses
Amongst maladies of increasing prevalence and importance are those communicable from animals to man. Salmonellosis, leptospirosis, brucellosis, Q fever, psittacosis are amongst the better known, but others of fungal, viral or protozoal origin may be more prevalent and far more important than is at present realised. Serological surveys have disclosed that the amount of illness and invalidity caused by the better known infections is far in excess of their recognition by the practising profession.
It is necessary that medical practitioner be made aware of the nature of these infections, quick to perceive their incidence, thorough in his examination and where required competent and meticulous in reporting upon them. The incidence and distribution of a number of these conditions is not known owing to uncertainty of diagnosis and imperfection of notification. Were more known of their prevalence and distribution and the circumstance of infection, effectual and ready means of prevention might become apparent.
(b) Virus Infection
Recent advances in the study of virology have disclosed that prevalence of a number – now exceeding 70 – of viruses causing disease in man. Th clinical conditions following infection by these viruses commonly remain inaccurately diagnosed, roughly classified as pyrexia of unknown origin, upper respiratory tract infection, or suspect non paralytic poliomyelitis.
Broadly the new pathogenic agents may be grouped as:
- Enteroviruses including Coxsackie and ECHO viruses. The clinical conditions caused include herpangia, epidemic pleurodynia, aseptic meningitis, epidemic exanthemata, myocarditis neonatorum and acute febrile respiratory illnesses (summer grippe)
- Adenoviruses causing acute respiratory disease, acute febrile pharyngitis, pharyngo conjunctival fever, virus pneumonia.
The amount of invalidity and loss of working time occasioned by these viruses cannot be precisely determined but is believed to be considerable. The efficacy of inactivated virus vaccines demonstrated by Salk now gives reason to hope that specific vaccines prepared from one or more of these viruses may be found effectual in preventing the development of clinical disease.
For the study of these diseases the practitioner may be asked to co-operate in prompt notification, careful preparation of a clinical report and in the collection of faecal specimens, throat washings and paired sera for laboratory examination.
The organisation suggested will permit large scale investigation by securing the enlightened co-operation of the profession in widely dispersed areas during non epidemic period.
- SCHOOLS MEDICAL SERVICE
The policy of Health Departments maintaining schools medical services is that every child shall be submitted to medical examination at least three times during his school life – once on entry, once half way through his course, and once just before leaving.
Children requiring investigation or remedial treatment will of course be seen more frequently. The children are inspected by a full-time departmental medical officer but are referred for investigation and/or remedial treatment to a private practitioner. The parent may or may not comply with the recommendation to seek medical advice and the practitioner consulted may or may not accept the opinion of the schools medical officer that investigation and/or treatment are required.
In some States nurses assist medical officers by conducting part of the examination. Usually their responsibilities extend only to weighing, measuring the height and inspecting for skin and other conditions to which the medical officer’s attention should be called. In some States at some time they have been entrusted with the testing of eyesight and hearing. This incursion into the specialist’s field tends rather to detract from the argument that it is necessary to have a specially trained schools medical officer for the examination of school children rather than to permit this work to be undertaken by the general practitioner.
It seems logical that routine examination of the school child should be conducted by the local practitioner who after all sees the child and treatments him not only when he is sick but also when he is referred for attention by the schools medical officer. Theoretically at least, by permitting the recording of immunisation and illnesses, a schools medical service organised on the basis of a general practitioner service would permit completion of a more detailed and useful health record for each child. It would assure more frequent examination and more prompt attention. In such a service the schools medical officer cold be elevated to specialist status as a Consultant Paediatrician thereby relieving him of much of the drudgery of routine examination and binging to the country practitioner an opportunity of consultation not a present readily available.
Objections to this form of practitioner service have been:
- Where a number of practitioners practice in a district it would be difficult to get general approval for any one or more of them to conduct examinations of school children as a routine unless each child were punctiliously referred to his own family doctor. This might be difficult or impossible in certain cases and disputes might be many and bitter.
- Some practitioners might use the opportunity to attract extract work and fees for themselves by recommending unnecessary procedures.
- The unscrupulous practitioner could by suggestion or more directly undermine the confidence of a parent in a competitor.
- Practitioners could not be relied upon to be punctual and meticulous in the performance of the work and in the completion of the necessary records.
It seems that none of these objections would be insuperable if careful thought were given to organising the service within the doctor’s practice. Any imperfections of such a system would at worst be no greater than those which attend the present procedure. It would but be necessary to achieve general agreement amongst practitioners to plan the method carefully and to establish some local organization permitting supervision and administration.
The organization proposed would provide the opportunity for a thorough review of child health procedures and permit and enlightened decision upon the value and practicability of practitioner co-operation with the Schools Medical Service in examination treatment and recording.
The organization proposed would provide the opportunity for a thorough review of child health procedures and permit an enlightened decision upon the value and practicability of practitioner co-operation with the Schools Medical Service in examination treatment and recording.
- SURVEILLANCE AND TREATMENT OF DISEASE
In respect of some chronic communicable infections of a serious nature, the Health Authority may choose to rely for control upon careful supervision and effectual treatment of the patient. As examples there may be considered:-
(a) Malaria. In some parts of Australia where malaria is endemic and sometimes epidemic, environmental conditions completely preclude effectual control by measures directed against the vector. On the other hand infection is repeatedly re-introduced to the area by the movement of persons infected locally or overseas.
In these circumstance reliance must be placed upon prompt and accurate diagnosis and elimination of the parasite by curative treatment. An approved treatment for the asexual cycle must be supplemented by an approved prophylactic treatment to eliminate the sexual cycle and to prevent relapse. The patient must be kept under careful observation in case these objectives are not reached by the first course and so that in this event a second treatment may be given promptly. Successful application of these measures involves the conscientious co-operation of both medical practitioner and patient. The Health Authority must rely upon the practitioner to secure the co-operation of the patient.
(b) Leprosy. A more tolerant view of the patient suffering from leprosy has led to earlier release from isolation hospitals for treatment under conditions of home isolation. Secondary cases in the household must be expected unless certain prophylactic measures are conscientiously applied. For the supervision and treatment of discharged cases of leprosy and for surveillance of the members of the households in which they live, the Health Authority must depend upon the family practitioner. The close co-operation of the latter with the Department will be needed to assure that he is fully informed of the duties expected of him, of the conditions on which he must report, the treatment he must prescribe and the restrictions he must impose.
For the successful application of prophylactic measures of this type not only must the practitioner be made aware of the principles involved and of the purpose of the Health Authority in applying them, but the Health Authority itself must know the practical difficulties to be met so that mutually satisfactory changes in procedure may be made where necessary to suit the convenience of the practitioner.